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IMAGE  EVALUATBON 
TEST  TARGET  (MT-3) 


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Photographic 

L-ciences 
Corporation 


33  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4 5G3 


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CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICIVIH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


Technical  and  Bibliographic  IMotes/Notes  techniques  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best 
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which  may  alter  any  of  the  images  in  the 
reproduction,  or  which  may  significantly  change 
the  usual  method  of  filming,  are  checked  below. 


D 


D 


D 


D 


Coloured  covers/ 
Couverture  de  couleur 


I      I    Covers  damaged/ 


Couverture  endommagde 


□    Covers  restored  and/or  laminated/ 
Couverture  restaurde  et/ou  pelliculde 


I      I    Cover  title  missing/ 


Le  titre  de  couverture  manque 


I      I    Coloured  maps/ 


Cartes  g^ographiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 


□    Coloured  plates  and/or  illustrations/ 
Plan 


fiches  et/ou  illustrations  en  couleur 


Bound  with  other  materia!/ 
Reli6  avec  d'ai'tres  documents 


r~r|    Tight  binding  may  cause  shadows  or  distortion 


along  interior  margin/ 

La  re  liure  serrde  peut  causer  de  I'ombre  ou  de  la 

distortion  le  long  de  la  marge  intdrieura 

Blank  leaves  added  during  restoration  may 
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II  se  peut  que  certaine^  pages  blanches  ajout^es 
lors  d'une  restauratior  apparaissent  dans  le  texte, 
mais,  lorsque  c^ls  dtait  possible,  ces  pages  n'ont 
pas  6t6  filmdes. 

Additional  comments:/ 
Commentaires  suppldmentaires; 


L'Institut  a  microfilm^  le  meilleur  exemplaire 
qu'il  lui  a  6t6  possible  de  se  procurer.  Les  details 
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point  de  vue  bibliographique.  qui  peuvent  modifier 
une  image  reproduite,  ou  qui  peuvent  exiger  une 
modification  dans  la  mdthode  normale  de  filmage 
sont  indiquds  ci-dessous. 


I      I    Coloured  pages/ 


y 


D 


Pages  de  couleur 

Pages  damaged/ 
Pages  endommagdes 

Pages  restored  and/oi 

Pages  restaurdes  et/ou  pelliculdes 


ry\    Pages  damaged/ 

I      I    Pages  restored  and/or  laminated/ 


Pages  discoloured,  stained  or  foxefV 
Pages  ddcolordes,  tachetdes  ou  piqudes 


I      I    Pages  detached/ 


Pages  ddtachdes 

Showthrough/ 
Transparence 

Quality  of  prir 

Quality  indgale  f'.a  I'mpression 

Includes  sufiplementary  materii 
Comprend  du  matdrie'  suppldmentaire 

Only  edition  available/ 
Seule  Edition  disponible 


r~p\  Showthrough/ 

I      I  Quality  of  print  varies/ 

I      I  Includes  sufiplementary  material/ 

I      I  Only  edition  available/ 


Pages  wholly  or  partially  obscurod  by  errata 
slips,  tissues,  etc.,  have  been  refilmed  to 
ensure  the  best  possible  image/ 
Les  pages  totalement  ou  partiellement 
obscurcies  par  un  feuillet  d'errata,  une  pelure, 
etc.,  ont  6t6  filmdes  d  nouveau  de  fapon  d 
obtenir  la  meilleure  image  possible. 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  filmd  au  taux  de  reduction  indiqui  ci-dessous. 

10X  14X  18X  22X 


26X 


30X 


y 


12X 


16X 


20X 


24X 


28X 


32X 


The  copy  filmed  here  has  been  reproduced  thanks 
to  the  generosity  of: 

Harold  Campbell  Vaughan  Memorial  Library 
Acadia  University 


L'exemplaire  filmd  fut  reproduit  grfice  d  la 
g6n6rosit6  de: 

Harold  Campbell  Vaughan  Memorial  Library 
Acadia  University 


The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  specifications. 


Les  images  suivantes  ont  6t6  reproduites  avec  le 
plus  grand  soin.  compte  tenu  de  la  condition  et 
de  la  nettetd  de  l'exemplaire  film6,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 


Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


Les  exemplaires  originaux  dont  la  couverture  en 
papier  est  imprim6e  sont  film6s  en  commenpant 
par  le  premier  plat  et  en  terminant  soit  par  la 
dernidre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration,  soit  par  le  second 
plat,  selon  le  cas.  Tous  les  autres  exemplaires 
originaux  sont  filmds  en  commenpant  par  la 
premidre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  et  dn  terTimant  par 
la  dernidre  page  qui  comporte  une  telle 
empreinte. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  —^(meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 


Un  des  symboles  suivants  apparattra  sur  la 
derni6re  image  de  cheque  microfiche,  selon  le 
cas:  le  symbole  —^  signifie  "A  SUIVRE",  le 
symbole  V  signifie  "FIN". 


Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  largo  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  iilustrate  the 
method: 


Les  cartes,  planches,  tableaux,  etc.,  peuvent  dtre 
filmds  d  des  taux  de  reduction  diffdrents. 
Lorsque  le  document  est  trop  grand  pour  dtre 
reproduit  en  un  seul  clich6,  il  est  film6  d  partir 
de  Tangle  sup6rieur  gauche,  de  gauche  d  droite, 
et  de  haut  en  bas,  en  prenant  ie  nombre 
d'images  ndcessaire.  Les  diagrammes  suivants 
illustrent  la  mdthode. 


1 

2 

3 

1 

2 

3 

4 

5 

6 

1^ 


'•fi 


/. 


^:/^<  ^^- 


>iA 


Ibca's  Scries  of  Pocket  Tcxt«5ooi<s. 

OBSTETRICS. 


A  MANUAL  FOR  STUDENTS  AND  I'UAnTTIOXERS. 


BY 


DAVID   JAMKS    KVAXS,  M.D., 

Loliinr  on  Oh.<l,l,i,:,  and  J>ism.scs  of  Injann/,  Mrdill   r„ln  ml;,,  Mnutna/,  r,„„„/„. 
Fe/low  oj'  the  Obftctrintl  Sucitl!/,  l.undoii,  Kuijland. 


sf:rii;s  kditki)  uy 


BERN    I}.   (fALLAUDET,    M.I)., 

DnunnMrator  of  Anntounj  ,u,d  m.tnn-lor  in  S,n;rn,  r,M,yr  ,,  nj,„,,  „„„  ,„,,,„„,^ 
Culumfna  rnurr.it,,  Xav  Vork ;  Visiti,,,  Su.ynn,.  iHlrmr  llus,,iud,  .^V  „■  y,,,-,:. 


ILLUSTRATED  WITH  ONE  MLNDRED  AND  FORTY-NINE 
ENGRAVINGS. 


LEA    BROTHERS   c^-    CO., 
PHILADEEPHIA    AND    NEW    YORK, 


KiikTL'il  iict'drdiiif:  tn  Acl  dl'  ('()iiKr(.'.ss,  in  tlu'  year  I'.Hio,  Ijy 

I.KA    nUOTlIKUS   &   CO., 

Ill  llii'  Ollicf  iif  tlu!  Liljriu'iiiii  of  Coiij^ross,  ill  \Vashiiig!ua.    All  riglils  rcscrvuil. 


'f  i^  ^^  9 


WESTCOTT    &    THOMSON, 
ELECTROTYPEHS,    PHILADA. 


PREFACE. 


TliK  aim  of  tlie  autlior  in  writing  this  "  juxkot  t('xt-))0()k  " 
lia.s  been  to  sii|)j)lya  short,  concontratcd  treatise  <ni  the  scieiur 
and  art  of  ohstetiies,  a  work  tliat  tlie  stiuk'nt  and  junior 
practitioner  may  find  of  use  in  attendance  (in  lectures  or  in 
evcrv-dav  i)ractico. 

Tlie  j)hysiolo<>:y  of  pregnancy,  of  labor,  and  of  the  puer- 
perium  has  been  dealt  with  rather  fully,  Ix'lnre  the  considera- 
tion of  their  patholoiry. 

Normal  labor  and  tlu^  more  fi'e(juent  diflicnlties  have  been 
dwelt  on  at  some  leni^tli,  while  the  rarer  conditions  and  more 
comj>licate(l  operations  have  been  deseribed   moi'e   in  outline. 

In  order  t(»  condense  the  work  as  fai"  as  possible  the  con- 
sidei'ation  of  the  phvsiolojxv  and  palliolou;v  of  the  iicirhoni 
has  been  dispensed  with,  these  subjects  beiiiu'  <liscussed  fully 
in  the  volume  (tn  "  l*(vliatrics  "  belonuiuu.-  to  this  seri{\s. 

To  iucreas(>  tlie  j)ra(;tical  usefulness  i)t'  the  book,  a  special 
eHbrt  has  been  made  to  combine  conciseness  with  clearnvss, 
and   to  keep  it  within  a  convenient   number  of  |):i«i'es. 

The  standard  works  on  obstetrics  have  been  larufcly  drawn 
from,  particularly  those  of  Jewett,  Hirst,  Playfair,  etc. 

The  author  takes  this  o])]iortunity  to  acknowledu-c  his 
indebte<lness  to  Dr.  V.  Morlev  I'^rv  for  his  advice  and  assist- 
ance in  correctii^ij:  j)roof,  and  to  Di-.  li.  I>.  (iallaudcl  for  his 
l)ainstakini2:   work    in   editinu'  the   book. 

MoxTUEAL,  Canada. 


XOXSfO 


CONTENTS. 


MENSTRUATION. 


TACK 


Dt'liiiitioii ;  cjuiso;  striU'tiiral  cliaii^t's ;  onset;    cli;'  at'tt'r;  (liinitinii ; 

iiK'ii(i|iaMsc 17,  is 

Ovii.ATidX  :  ( Iraaliaii  t'olliclo  ;  oviiin  ;  iiiatiiialion  ol' nviim  ;  cnipus 

liitfiim  ;  ovulatidii  and  menstruation lS-21 

PREGNANCY  (Normal). 

Emijuyolooy:  linprognatioti  and  conception;  scincn  ;  feiiilization 
of  tlie  ovnrn ;  developnieni  of  tlu'  (lei'i<liia  :  rellcxa  ;  vera; 
layers  of  (leci<hia;  decidual  cells;  changes  in  the  ovutn  ;  de- 
velopment of  the  fd'tus;  segmentation;  lilastodennic  vesicle; 
cleavage;  development  of  tlu>  memhranes  ;  aiiniion;  yolk-sac; 
aiiantois;  lu'achus;  innhilical  cord;  chorion:  development  nf 
the  placenta  ;  structure;  villi;  capillaries;  iilacenta  and  meni- 
hranes  at  term;  functions  of  [)lacenta  ;  ovum  at  diflercni  periods 
of  liregnancy ;  fo'tal  circulation 21   8S 

CiiAN(;i:s  IN  Matkun'AI,  Ohoanism  :  Items;  increase  in  size; 
changes  in  shape  and  structure  ;  relation  to  pelvis  and  ahdonuMi ; 
alterations  in  cervix,  vagina,  and  vulva;  changes  in  hreasts  ; 
alterations  in  other  than  the  generative  organs;   lincic  alliica?Ues    .'W— 1 1 

Duration  OK  Piuocjnancy  :  Date  of  fruitful  coitus  ;  rule  for  deter- 
mining; height  of  fundus  uteri  ;  date  of  (luickening M,  4') 

DiAfiNosis  OF  Phi:(;nan('Y  :  First  trimester:  su|)pression  of  nuMi- 
struation  ;  nausea  and  vonuting;  mannnary  changes;  vesical 
irritation;  nervous  disorders;  softening  of  cervix;  violet  dis- 
coloration of  vagina  ;  softening  and  enlarn-cnu-i.i  of  liody  of 
uterus;  second  trimester:  fretal  movement;  uterine  soullle  ; 
fo'tal  heart-sounds;  i»ignientalion ;  hallottemeut  :  third  tri 
mester  :  pressure-symptoms  ;  varices;  disturliancesof  res|»iration 
and  digestion ;  fa'tal  movements;  striie;  settling;  siunmary  of 

5 


6  CONTENTS. 

I'AdK 

(liiifi^nosis;    (lilU'reiilial  diafijiio.sis  of    pregiumrv ;    dingnosis  of 
parity  or  milliitiiiity  ;  (liaf>;ii()sis  ol' life  or  (leath  of  child    .    .    .      45-51 
IlytiiKNK  AND  MANA(ii;MKNT  «)K   I'uKONANCY  :    Diet;   I'xercise ; 
c'lotiiiii}^;  hathiiifj: ;  care  of  breassts ;  care  of  other  organs  and 
fiUK'tions ;  examination o4-r)() 

OBSTETRIC  ANATOMY. 

Anatomical  Klkments  in  Laisur 56,57 

Tin;  Utkius:   Walls;  niiiscle-lihres ;  uterine  segments;  ligaments; 

peritoneum  ;  relation  of  full-term  uterus  to  eontiguou;  structures      57-61 

TllK  I'i';i,vi-(iKMTAh  Canal:  JJoiiy  pelvis:  general  description  ; 
joints;  moliility  of  pelvic  joints;  false  and  tiue  pelvis;  inlet; 
sui)erior  strait;  inferior  strait;  outlet;  cavity  of  privis;  lat- 
eral grooves;  i)i.nies  of  i)elvis  ;  pelvic  diameters,  conjugate; 
transverse;  ol)li(iue  ;  measurements;  inclination  of  the  pelvis; 
soft  pai's  of  the  pelvic  canal  :  nuiscles  ;  rectum  ;  {)elvic  floor; 
segments  of  (loor  ;  fascia  ;  j)erineinn  ;  i)arturient  axis  ;  other 
axes 61-76 

Thk  Imktis:  Mature  folus ;  the  head:  vault;  base;  sutures; 
fontanelles;  ob.stetric  landmarks  ;  diameters  of  fa'tal  head  ;  cir- 
cumferences of  planes  of  fo'tal  head  ;  moulding  of  head  ;  im- 
|M»rfance  of  (lexiou  of  head  ;  Ortal  trunk  :  diameters;  mobility 
of  lie;id  and  trunk  ;  postiu'c  of  fo'tus  ;  presentations;  cephalic, 
pelvic,  somatic;  positions;  vertex,  face,  breech,  .shoulder; 
centre  of  gravity  of  fietus;  Aetal  movements 76-96 

MECHANISM  AND  COURSE  OF  NORMAL  LABOR. 

(lENKiJAT,  Dkfinitiox.'S  ani>  IvriOT.odY:  Kut(H'ia  ;  uncomplicated 
vertex  present:itions ;  primigravida ;  priinii)ara;  nudtipara; 
stages  of  labor ;  dm  ation  of  normal  labor  ;  causes  of  the  on.set 
of  lal)or  ;  forces  of  labor;  uterine  contractions ;  pains;  refr.ic- 
tion  ;  polarity;  contraction  of  abdominal  nmscles  and  dia- 
I  In-agm  ;  gravity 96-102 

Laiu)r — First  Staoe:  Premonitory  signs  and  symptoms;  charac-  , 

teristic  signs  and  sym])toms  of  the  onset  of  lal)or;  mechanism 
of  the  first  stage  ;  dilatation  of  cervix  ;  liydvostatic  i)ressure  of 
the  bag  of  waters ;  action  of  longitudinal  fibres  of  uterus ;  rupt- 
ure of  membranes;  ])rcsenting  ])art  of  fretus  as  dilator;  dry 
labors;  os  uteri ;  initial  labor-pains;  reflex  vomiting;  anatomy 
of  soft  parts 102-107 


CONTENTS.  7 

I'AtiK 

Laiiok— Skcon'I)  Stauk:  Mecliaiiism  ;  lu-atl  iiiovcim-iit  ;  doceiit  ; 
llfxidii  ;  inleriKil  rotatimi ;  exloiisidii  ;  ivstitiitioii  or  eMenuil 
rotation;  delivery  of  tlie  trunk;  jiains;  sufRTiii;;s  of  woman; 
aftor  the  birili  of  the  I'hild  ;  nioiildini^  of  tin;  fo'tal  head; 
capnl    succedanenin ;    anatoniy I(»7    Hi; 

Laijok — Tjiiuu  Staok:  Separation  of  placenta;  separation  of 
nieinlwanes ;  expulsion  of  placenta  and  inetnhranes ;  retro- 
p'.acental  heniorrhaj,^e ;  eoinpletion  of  labor;  hlood  lost  in 
labor J  Itl   ll.s 

MANAGEMENT  OF  NORMAL  LABOR. 

OliSTHTUu;  Antiski'.sis:  Antiseptic  a<^ents  ;  chenncal  antise|)tii's  ; 
the  obstetrician;  inetliods  of  sterilizing  hands;  the  nnrse; 
tlie  patient 11 '.M'JX 

I'KErAUATloNS  FoK  I.ahoH:  On  the  part  of  the  j)h_vsician  ; 
obstetric  bag  and  contents  ;  labor  room  ;  linen;  vnlvar  pads; 
binders;  labor-bed;  anasthetics  in  labor 124   127 

Managkment  oi"  Tin-;  First  StA'se:  Preliminary  conduct  of 
the  physician  ;  obstetric  examination  ;  palpation  ;  auscultation  ; 
vauinid  examination;  succeeding  the  examination;  rupture 
of  M  embranes      128-13G 

Manackmknt  of  thk  Skconij  iSxAtiK:  Position;  in  rapid  cases; 
aniPsthesia;  perineal  stage;  laceration  of  perineum;  at 
moment  of  delivery;  delivery  of  head  ;  delivery  of  shotdders  ; 
immediate  care  of  child;  the  cord 137-140 

MANA(iKMKNT  OF  TiiK  Thiut)  Staof,  :  To  insure  lirm  uterine 
contract!. )n ;  lacerations;  e.\])ulsion  of  placenta;  Crcde's 
method  of  expression;  retraction  of  uterus;  final  measures    .  141,  142 

THE  PUERPERAL   STATE. 

Anatomy  of  thf  Parts  immkoiaiklv  aftkk  Lahoi!  :  Tiie 
uterus;  vagina;  vulva;  bladder;  peritoneum;  abdominal 
walls 143-140 

PiiYsioi.OfJY  OF  THE  PrERi'ERAL  Pehioii  :  Involution;  circula- 
tory system;  urinary  system;  skin;  digestive  apparatus; 
lactation;  mammary  glands;  colostrimi  ;  milk       145-150 

Manauemext  OF  THE  PiERPERiUM :  Lying-in  room;  genitalia; 
care  of  breasts;  nursing;  nipples;  contraindications  to  suck- 
ling; after-pains;  visits  of  the  physician;  infant's  tempera- 
ture     Io0-lo4 


'?< 


8  CON  TESTS. 

PATHOLOGY   OF  FllEGNANOY. 

PAOK 

'I'liK  I)i;(  IDIA  :  Aciiti-  and  clironuMlcfidual  nidoiiii'tritis;  atrophy  154-ir)t» 
Tin;  I'd/iAi,  A  l'i'i;M)A*ii:s:  ( Hinoliydraimiios ;  liydraniiiios ; 
amuiniic  l.iiids;  prciiiatiirc'  riiptiiiu  of  aiiiiiioii ;  alterations  in 
('liarat'liT  of  iiijiior  anniii  ;  vi'siciilar  nioK';  anomalies  of  pla- 
(vnta  ;  disi-asi's  of  plact-nla  ;  plarcntal  apopk-xy  ;  placiMitilis; 
tumors  and  odema   of    placenta;    aijiiornial   lenj^tli    of  cord; 

coils  and  knots  of  cord;  hernia  into  cord lotl-Ki.) 

TiiK  lAivrfH  :  T<Miit(>lof,'y  ;  fo'tal  mortality ;  elciihantiasis;  a'la- 
sarca  ;  ii-hthyosis;  rachitis;  syphilis;  tubcrcidosis ;  contagions 
disiuses;  fo'tal  death Kio-ltJl) 

l'A'rii(),.()(iV  OK  TIIK  I'i!i:<iN'ANT  WoMAN:  Varices;  o-deiiia  ; 
pruritus;  leucorrlma  ;  ve,t,'etatioiis  ;  retroversion  i'.ud  prolapse 
of  uterus;  endocervicitis ;  tumors;  mamm;  ry  ahscess  ;  exces- 
sive secretion  of  milU;  ec/ema  of  the  nipples;  jiiuijivitis ; 
dental  caries ;  parotitis;  ptyalism  ;  inilii,'estion  ;  consti|)ation  ; 
diarrh'ca;  vomit iiiu^ ;  pernicious  vomitinir;  uterus;  hemor- 
rhoids; irrital>i!!iy  of  thehladder;  hietnaturia;  alhuminui'ia  ; 
kidney  of  jireynaney  ;  acute  and  chronic  nephritis;  coutih  ; 
dyspna'ii;  pneumonia;  phthisis;  cardiac  ilisease  ;  heart  nnir- 
nnirs  ;  eid;ir^ement  gf  thyroid  ijlaud  ;  neuralgia;  neuroses; 
infectious  diseases 109-188 

ToXilCMiA — Kci.  A.Mi'siA:  Symptoms;  definition;  frecji  Micy  ;  pre- 
monitory symptoms;  the  lit  ;  etiology;  path()lof>^ical  anatomy  ; 
treatment 188-101 

AnoirnoN  an'd  Pi;i;MATiitK  Lahok:  Detinition;  symptoms; 
patludogy;  etiolo^'y  ;  diagnosis;  treatment;  missed  ahor- 
tion  ;  miscarriage  ;  missed  labor r.)4-201 

1m  roric  Gkstation  :  Detinition;  frecpiency ;  varieties;  tubal 
pregnancies;  terminations;  tubal  abortion;  etiology;  path- 
ology ;  symptoms ;  treatment ;  removal  of  sac  ;  techni(pie  of 
operation 202-2(1'.) 


PATHOLOGY  OF  LABOR. 

Dystocia  due  to  Malpositions  of  tiik  F(Ktis:  Occipito- 
posterior  cases  ;  face  presentations  ;  brow  presentations  ;  breech 
presentations  :  arrest  of  breech  at  the  brim  ;  rapid  I'xtraction 
of  trunk  ;  delivery  of  tlie  after-coming  head;  transverse  pres- 
entations ;  prolapse  of  the  fietal  liMd)s  ;  ))lural  Itirths      .    .       20'.*  218 


V(fSTh\\TS.  9 

I'AtiK 
I)YST()C1A  Dl'K  TO    A  N(»M  A  1,1  i:s  ol'    I'tKI'AI,  I  )|:Vi:i.' H'M  i:n  T  :    OviT- 
;;r(i\vtli  of  I'm  1 1  IS  :  |Hiiii;iliiri'  ()>HirK;ili()ii  nl'  >kiill  ;  liy(lr(i(r|i|iii- 
liis;  i.'iut.'l>liiilti(i'lf  ;   inciiiii^'<i(vli' ;   livdrriici'itlialiis ;  liiiiiurs  nl 

tniiik  ;  imeiuvpliMliis  ;  doultlo  moii.slL'rs 21S-2");) 

hrsidciA  III  i;  ru  Ai'.n<»i;.\ia!.ii  ii;s  oi.  riii:  I'd/rvi,  Ai-niNDAciKs ; 
Slmri  curd  :  |iiiil;i|isr  dI'cihiI  ;  cuiliiii^'  of  curd  mIxiiii  fnl;il  iiccU  ; 
|iliHTiil!i  pniviii  ;  iiccidc'iitiil  liciii(inli:i;,'t' ;  iiiiMiiiitiiic  .scjiara- 
tioii  of  a  normal Iv  isitiiatc-*l  itlaci'tita  ;  rclaiiuil  iilacciila  ;  ad- 
liiTi'iit  iilai'fiita lioo-UtiK 

M\ri;i;NAi,  hv^iociA  :  l'iTci|iitatc  labor  :  di'la\  rd  lalior  ;  iilciiin' 
iiu'ilia  ;  aiioiiialirs  of  llu'  |iclvi>  ;  |ifiviiiK'l'y  ;  aiioiiialic^  of 
iilfriiit'  di'Vflopiiic'iit  ;  alri'.sia  and  rigidity  of  cervix  ;  iiii|i:ii  tioii 
of  anterior  lip  of  cfrvix;  (lispL.t'i'int'iils  of  llu-  ntcriis;  pro- 
laphc;  aliiu>rmal  coiKlilioiis  of  vagina,  vnlva,  and  Madder; 
tumors  of  u:eiiital  canal  ami  neiy:lil)oriiij,'  or^ians;  rupture  of 
litems;   inversion  of  the  nterns      "JtiS-lU'J 

PATHOLOGY   OF   THE   PUERPERAL   PERIOD. 

IIemoiujii  AiiKs    in  i!iN<i    iiiK    I M  Ki!  I'KK  1 T  M  :    ro>t-partum  lie.liol- 

riiaije;  secondary  liemoiriiaii:e  ;   lia'mat.una 312-318 

SiT.iNVoi.i  iiox  :   l';tiolo,iry  ;  diagnosis;  treatment 31H-320 

Anomai.iks  and  I)iskasi:s  of  tiii:  Xiitj.ks  and  I>I!i:asts: 
Supernumerary  nipples;  inversion  of  the  nipple;  ahsence  of 
inamiiia';  liypenropliy  of  mamma';  supernniiKMary  mamma'; 
defii'ient  milk-secretion  ;  polygalactia  ;  ualactorrlnea  :  eng-orye- 
inent  of  the  hreast  :  sore  nipples;  mastitis;  mainmary  ahscess  ; 
arrest  of  lactation 320-332 

I.\Ti.i!(  I  I!I!i:nt  Diskasks  IX  TiiK  I'rKKi'iiiiif.M  :  >[iscellaneons 
diseases;  malaria;  piKM']K'ral  ana-inia;  liemorrlioids  ;  diseases 
of  the  urinary  ortfans  ;  neuritis  ;  myelitis  ;  cerebral  heniorihage 
and  embolism  ;  i)uerperal  insanity;  snd<lon  death  ;  pulmonary 
end)olisin  and  thrombosis;  entranee  of  air  into  uterine  sinuses  ; 
fever  oilier  than  septic  ;  puerperal  septic  infection 332-3(11 

OBSTETRIC  OPERATIONS. 
Kpisiotomy  ;  immediate  repair  of  vaijinal  and  perineal  lacerations  ; 
iininediatc  repair  of  cervical  lacerations;  induction  of  abor- 
tion ;  induction  of  premature  labor  ;  forceps  operations;  ver- 
sions; external,  bipolar,  internal  version;  syinphysintomy  ; 
Cse.sarean  seetion  ;  I'orro  operation  ;  f,'eneral  rules  yoverninj^ 
.selection  of  obstetric  opeiations  ;  embryotomy 361-417 


OBSTETRICS. 


MENSTRUATION. 

Menstruation  is  a  periodic  discharge  of  blood  and  mucus 
from  tlie  uterus  and  the  Fallopian  tubes  of  the  woman  during 
the  period  of  sexual  activity — /.  c,  from  puberty  to  the  meno- 
pause. 

The  cause  of  menstrufition  is  unknown.  Many  theories  have 
been  advanced  ;  but  all  that  can  be  said  is  that  nervous  inf  nonces 
proceeding  from  the  sympathetic  nerve-ganglia  in  the  lower 
abdomen  and  pelvis  periodically  bring  about  a  condition  of 
congestion  of  the  sexual  organs. 

It  is  presumed  that  the  function  is  analogous  to  "  rut "  in  the 
lower  animals,  and  that  from  the  erect  posture  of  the  woman, 
the  pelvic  congestion  results  in  bloody  discharge. 

Structural  changes:  According  to  Leopold,  the  intra-uterine 
mucous  membrane  becomes  thickened  and  softened  almost  to 
liquefaction,  but  remains  practically  intact  throughout,  while 
it  is  quite  distinct  from  the  paler  muscular  tissue  of  the  uterus. 
The  uterine  glands  are  swollen  and  lengthened.  In  the  super- 
ficial portion  of  the  endometrium  is  an  enormously  distended 
network  of  capillaries.  As  the  venous  return  is  slower  than 
the  arterial  supply,  there  occurs  a  diapedesis  of  blood.  This 
blood,  along  with  an  excess  of  mucus  from  increased  activity 
of  the  uterine  glands,  forms  the  menstrnal  discharge. 

The  onset  of  menstruation,  or  puberty,  varies  in  different 
countries,  occurring  earlier  in  southern  than  in  northern  cli- 
mates. Generally  in  temperate  climates  it  a})pears  about  the 
fourteenth  year.  It  is  more  likely  to  come  on  earlier  in  city- 
bred  than  in  country-bred  girls. 

Character  of  the  flow :    The    flow   is   chiefly  composed  of 
I  blood,  but  also  contains  mucus  and  epithelial  detritus. 

f  It  has  a  peculiar  odor,  which  is  more  marked  in  briuiettes 

2— Obat.  17 


i 


18  MENSTRUATION. 

than  in  blonderf,  and  is  caused  by  secretions  from  the  sebaceous 
glands  at  the  vaginal  outlet. 

The  discharge  is  dark  in  color,  as  a  rule  does  not  clot,  and  is 
alkaline  in  reaction. 

Duration  and  quantity:  Menstruation  lasts  from  three  to 
seven  days.     As  a  rule,  it  occurs  every  twenty-eight  days. 

The  actual  quantity  of  the  discharge  is  from  four  to  six 
ounces. 

Menopause :  Menstruation  ceases  in  the  forty-fourth  year 
usually ;  but  there  are  many  exceptions.  As  a  rule,  a  woman 
menstruates  during  a  period  of  about  thirty  years. 

The  cessation  of  menstruation  is  termed  the  menopause  or 
climacteric. 

Ovulation :  By  this  term  we  designate  the  process  of  forma- 
tion, development,  and  discharge  of  a  mature  ovum  from  its 
Graafian  follicle  in  the  ovary. 

The  Graafian  follicle  is  derived  from  the  germinal  epithelium 
on  the  surface  of  the  ovary.  These  cells,  becoming  isolated  in 
the  stroma  of  the  ovary,  develop  a  special  containing  mem- 
brane from  the  theca  foUiculi,  which  becomes  divided  into  two 
layers,  the  tunica  fibrosa  and  the  tunica  propria.  The  epi- 
thelial cells  develop  and  line  this  membrane,  forming  themcm- 
hrana  granulosa,  and  a  fluid,  the  liquor  folliculi,  distends  the 
cavity. 

One  of  the  epithelial  cells  of  the  membrana  granulosa  be- 
comes more  highly  specialized,  the  ovum,  and  is  surrounded  by 
an  aggregation  of  cells,  the  discus  proliger us  (Fig.  1). 

It  has  been  calculated  that  at  birth  each  ovary  contains 
35,000  immature  follicles.  These  do  not  develop  till  about  the 
time  of  puberty,  when  one  or  more  rapidly  mature  and  rupt- 
ure. The  escape  of  its  contents  takes  place  each  month,  the 
process  being  re|)eated. 

As  the  follicle  matures  it  approaches  the  surface  of  the  ovary, 
the  liquor  folliculi  increases  till  it  points  at  the  surface,  rupt- 
ures the  tunica  pro|)ria  and  washes  out  the  ovum  surrounded 
by  its  discus  proligerus. 

The  ovum  is  then  swept  into  the  fimbriated  extremity  of  the 
Fallopian  tube,  through  which  it  passes  into  the  cavity  of  the 
uterus. 


MENSTH  UA  TION. 


19 


The  ovum :  The  hnindtnrc  ocum  is  a  simple  epitlielitil  cell 
witiiout  a  cell-wall,  but  having  eell-oontcnts — /.  <.,  the  yolU,  a 
nucleus  termed  the  germinal  vesiele,  and  a  nucleolus  called  the 
germinal  spot  (Fig.  2).  It  early  develops  two  walls,  the  outer, 
termed  the  vitelline  meuibrane ;  the  inner,  the  eell-memhrane. 
Between  tiiese  walls  is  a  clear  area,  termed  the  zona  pelhicida. 

As  the  ovum  iiiatures  previous  to  its  eseaj)e  from  the  Graafian 
follicle  its  germinal  spot  approaches  the  cell-membrane,  where 

Fig.  1. 
KE        PS 


Development  of  the  Graafian  follicle:  £'E,  jjerrainal  ejiitheliiim,  from  which 
Pfliiger's  tubes,  PS,  in  ovarian  stroma  are  developed  ;  .s'o,  ovarian  stroma  ; ;/,  (7,  small 
vessels;  U,  (.'.primitive  ova;  S,  space  between  membrana  granulosa  and  oviim  ;  /,/, 
liquor  follicnli ;  I),  discus  proligerus:  Ei,  ripe  ovum,  with  perm-vcsiele  and  ger- 
minal spot  ( A') ;  Mp,  membrana  pellucida ;  ly,  muscular  sheath  of  follicle ;  Mg,  mem- 
brana granulosa.    (VViedersheim.) 

it  seems  to  disappear,  and  a  portion  of  the  ovum  is  extruded, 
known  as  the  first  polar  body.  After  a  stage  of  quiescence 
the  process  is  repeated,  and   a  second  polar  body  is  extruded. 

Then  appears  a  new  and  smaller  germinal  spot,  termed  the 
pronucleus. 

When  these  phenomena  liave  taken  place  the  ovum  is  mature 
and  the  Graafian  follicle  ruptures. 


20 


MENSTRUATION. 


The  corpus  luteum:  After  the  escape  of  the  ovum  the  rupt- 
ured (rraafiiin  follicle  becomes  filled  with  blocnl,  which  clots 
'\w\  a  Hue  capsule  develops  arouud  it,  which  gradually  becomes 
thickeued  and  thrown  into  folds.  This  formation  is  termed  the 
corpus  lideuin,  from  its  yellow  color.  Should  pregnancy  not 
occar  by  the  twenty-eighth  day  it  shows  on  the  surlace  of  the 
ovary  merely  as  a  fibrous  lamina  in  a  little  })it. 

J^ut  in  prcfjiiancij,  from  the  prolonged  congestion,  the  corpus 
luteum  has  a  much  greater  development.     Forty  days  after 

Fi«.  2. 

I  8     9  lo     If 

\  111/ 


:\DoaosaoooauaDQOooooai)OogDaagpo^''<wcw'Mr/00 


Triansular  bit  of  ovarian  stroma  cut  from  ovary :  Magnified  to  show  firaafian 
follicle  and  ovnle:  1,  epithelial  covering  of  ovary;  2,  tunica  albiiRinea  (librous); 
?>, ;{,  (litt'erent  parts  of  stroma;  4,  Graafian  follicle  (tunica  fibrosa) ;  5,  Oraatian  vesicle 
or  ovisac  ;  6,6,  tunica  granulosa  ;  7,  liquor  f'olliculi ;  «,  vitelline  membrane,  or  zona 
pellucida;  9,  granular  vitellus,  or  yolk ;  10,  germinal  vesicle  ;  11,  germinal  spot. 

conception  it  has  a  diameter  of  about  two-thirds  of  an  inch 
(1.5  cm.).  At  term  it  is  still  present,  has  shrunk  to  half  an 
in(!h  (1  cm.)  in  diameter,  and  is  of  a  distinct  lemon-yellow 
color.  A  month  after  delivery  it  is  reduced  to  a  small  mass 
of  fibrous  tissue. 

Ovulation  and  menstruation  :  Neither  ovulation  nor  menstru- 
ation is  dependent  on  the  other. 

Both  depend  on  the  same  cause,  a  periodic  nervous  excita- 


IMPREGNATION  AND  CONCEPTION.  21 

tion  and  (•()ii<>;(.'Stion.  As  a  r\\\v,  they  do  occur  synclironoiisly  ; 
but  Lo()})ol(l  liavS  j)r()VO(l  tliat  ovulation  has  taken  place  in  the 
intcrinonstrual  ju'riod. 

Pregnancy  has  been  icnown  to  take  place  before  the  onset 
of  menstruation  and  after  the  climacteric. 

PREGNANCY  (Normal). 
EMBRYOLOGY. 

Impregnation  and  Conception. 

The  propagation  of  tlie  species  re(piires  the  union  of  the 
vital  elements  of  the  two  sexes. 

In  the  act  of  copulaiioii  the  male  deposits  within  the  female 
a  fluid,  tiie  semen,  which  contains  the  vitalizing  element. 

The  semen  is  a  white,  viscid,  dense  fluid  having  a  peculiar 
odor,  secreted  by  the  testicles  of  the  male.  It  consists  of  water, 
albuminous  matter,  salts  of  lime  and  sodium,  and  contains 
numerous  peculiar  organisms  called  Hpeniiatozoidn. 

These  spermatozoids  form  tiie  essential  fecundating  part  of 
the  semen,  are  about  g  ,\,j  inch  in  length,  and  resemble  tlie  tad])ole 
of  the  frog.  p]ach  one  is  made  up  of  three  parts  ;  head,  middU> 
})iece,  and  tail,  and  is  capable  of  very  rapid  vibratory  move- 
ment (Fig.  3). 

After  emission,  if  in  ])roper  surroundings,  ^Ki.  8. 

the  organisms  retain  their  vitality  for  a  con- 
siderable time.  Plxcessively  acid  or  alka- 
line fluids  destroy  them. 

While  })regnancy  has  been  known  to 
follow  the  (lej)osition  of  semen  on  the  ex- 
ternal genitals  of  the  female,  as  a  rule, 
the  acid  mucus  of  the  lower  vagina  })roves 
fatal  to  the  spermatozoids. 

At  the  crisis  of  the  sexual  act  the  semen 
is  usually  deposited  in  the  upper  portion  of 
the  vagina,  into  which   the  cervix  ])rojects.  spermato/.oi.is. 

Hence  the  sjx'rmatozoids  And  their  wav  into 
the  cavity  of  the  uterus,  and   ultimately   reach  the   Fallopian 
tubes.     They  have  been  found  on  the  surface  of  the  ovary. 


22 


PREGNANCY. 


As  a  rule,  tlie  meeting-place  of  tho  speriratozoid.s  r.nd  ovum 
is  ill  tlio  I'^illopiaii  tube.  Many  chiiin  tliat  the  normal  place 
of  inot'tiiiu;  is  the  upper  portion  of  the  uterine  oavi*  ;  and  it 
is  not  infVcijtient  that  tliev  come  in  contact  on  the  surface  of 
tiie  ovary  or  in  the  abdominal  cavity  (ectopic  gestation).  If 
the  ovum  is  discharged  at  the  height  "f  tlie  menstrual  conges- 
tion, it  probably  does  not  reach  the  cavity  of  tlie  uterus  fir 
some  days,  llyrtle  found  the  ovum  in  the  uterine  extremity 
of  the  tube  in  a  girl  who  had  died  on  the  fourth  day  of  men- 
struation. 

Pregnancy  is  more  Hkchj  to  occur  after  copulation  during  the 
first  eight  days  succeeding  the  cessation  of  menstruation. 

Fertilization  of  the  ovum:  Of  the  large  munber  of  sper- 
matozoids  deposited  in  the  vagina,  but  few  ju-obably  come  into 


Fig.  4. 


.'-f'n 


Lb  *  «  M    J 


\  • ,  •  <*  •  *ir  N-i:  »•  •• '» / 


Formation  of  polar  globules  in  artoria  glacialis :  Sp,  nuclear  spindle ;  Pg,  first 
])()lar  globule  ;  Spg,  seconii  polar  globule; /p,  female  pronucleus.     (After  0.  Hert- 

wig.) 


contact  with  the  ovum  ;  and  of  these,  but  a  single  s})ermatozoid 
actually  takes  part  in  the  fertilization  of  the  ovum. 

By  friction  with  the  walls  of  the  tube  the  cells  of  the  discus 
])roligerus  disa])})ear  and  the  zona  pellucida  becomes  surrounded 
with  an  albiuninous  covering  which  seems  to  attract  the  sper- 
matozoid. 

The  successful  spermatozoid,  after  penetrating  the  zona  pel- 


DKVELOPMENT  OF  THE   DECIDUA.  23 

liicida,  coiues  in  t.'ontact  witli  a  projection  oi'tlie  j)r<)to})la,sin  of 
tlu'  ovum  and  its  tail  disapjx'ars.  I'lic  head  then  penetrates 
the  cell-contents  and  (lisaj)pears,  to  reappear  subsequently  as  a 
sn-iall  round  body,  the  male  j>r()imcl<'un  (Fiji;.  4),  Finally  the 
male  pronucleus  and  the  female  ])ronucleus  unite,  and  concej)- 
tion  has  occurred,  'i'hus  the  lii'e-history  ot"  the  embryo,  i(etus_, 
and  infant  be<rins. 


-J3' 


Development  of  the  Decidua. 

While  the  above-descril)ed  processes  have  been  taking  place, 
leadinu;  to  the  fecini<lation  of  the  ovum,  preparations  have  been 
in  j)roi^ress  for  the  hitter's  reception  and  nourishment  within 
the  uterine  cavity. 

The  mucous  membrane  lininy:  the  bodv  of  the  uterus  becomes 
nnich  increased  in  thickness,  its  elands  enlar^in^  in  all  dimen- 
sions. The  linint^  membrane  of  the  uterus  during  pregnancy 
is  termed  the  deciduii. 

The  ovum  when  it  reaches  the  uterus  thus  finds  that  a  soft 
bed  has  been  prepared  for  it.  It  soon  settles  and  becomes 
adherent,  as  a  result  of  certain  auKeba-like  projections  (villi) 
which  have  formed  on  its  surface. 

The  ovum  once  fixed,  the  decidua  proceeds  to  grow  u|) 
around  it,  completely  imbedding  it  and  thus  shutting  it  off 
from  the  uterine  cavitv. 

Subdivisions  of  the  decidua:  The  decidua  lining  the  uterine 
cavity  is  termed  the  dccidna  vera;  that  portion  on  which  the 
ovum  has  come  to  anchor,  the  site  of  the  future  i)lacenta,  is 
called  the  decidua  serotina ;  while  that  portion  which  grows 
up  and  surrounds  the  ovum  is  named  the  decidua  reiiexa 
(Fig.  5).  '' 

Coalescence  of  reflexa  and  vera  :  As  the  ovum  grows  and 
distends  the  uterus,  the  decidua  reflexa  comes  in  contact  witli 
the  decidua  vera  throughout.  As  a  result  of  pressure  the 
outer  layers  of  both  reflexa  and  vera  then  undergo  consider- 
able atrophy.  This  takes  place  about  the  fourth  month  of 
gestation. 

Layers  of  the  decidua:  The  development  of  the  d,vidua1 

(//amis  leads  to  certain    changes  in   the  conformati )f  tlie 

decidua.     These  glands,  dilated  and  straight  toward  the  sur- 


24 


PREGNANCY. 


fhce,  bccoiiic  more  dilattd  iuul  tortuous  as  tlicy  pass  dowmvard 
to  tlic  miisciilar  uterine  wall.  As  a  result,  on  section  the 
(leeiduii  can  be  seen  to  be  composed  of  layers  of  ditl'ering  com- 
pactness. 

The  .siipfrjicid/  /((i/cr   is  cpiite   compact.     Pielow  this  is  a 
layer  which,  on  section,  has  a  reticulated  appearance,  the  so- 

Fi(i.  5. 


Scini-diaKrnniniatio  ontliiu'  nf  an  iintorn)Mist(rir,r  scotion  of  tho  Kravid  uterus 
and  ovum  of  five  wt'oks:  n,  antrrior  ntcrine  wall;  h,  posterior  (iterine  wall;  r,  do- 
c'idna  vera;  '/,  di'cidiui  reflexa;  r,  decldua  serotina ;  ch,  chorion  with  its  villi. 
(Modilk'd  from  Allen  Thomson.) 

called  xpongy  hn/cr,  or  ampvUnry  .sfrafum ;  wliilc  below  this 
ai2:ain,  in  contact  \vith  the  nuiscle-wall  of  the  uterus,  is  a  com- 
pact lavcr  tei'mcd  the  f<(r<(ti(in  compaofitni  {V\\t-  6). 

The  spongy  layer  is  of  prime  importance,  for  it  is  through 


CIIAyaiuS   IN  OVr'M:    HF.VKLOl'MEyr  OF  FiKTUS.      'if) 

this  layer  that  the  line  of  soparatioii  runs,  when  tlieiUriihiasero- 
tina  and  the  deciihia  vera  arc  ca^t  ofV  witii  tlie  })ia('enta  and 
nieinhranes  at  tlie  conchision  (»!'  lahor. 

In  tlu't,  the  d('('i(hia  may  Ix;  compared  to  a  cake,  wliich  is 
composed  ot"  two  compact  layers,  between  which  is  a  layer  of 
jam.  If  the  attempt  is  ma<le  to  sepaiate  these  two  layers  of 
cake,  the  line  of  separation  will  run  through  the  jam  (whicii 

Fi(i.  <;. 


Section  throutjh  the  decidua:  a,  imnion ;  h,  chorion;  r,  dccidua;  d,  iiterine 
muscle;  <',  lino  of  separation  in  the  cellular  layer;/,  cellular  layer ;  .7,  glandular 
layer.    (Friedliinder.) 

corresponds  to  the  spongy  layer  of  the  decidua),  a  considerable 
portion  of  which  will  come  away  adhering  to  the  toj)  layer  of 
the  cake,  while  some  of  it  will  still  be  left  on  the  lower  layer. 

Decidual  cells :  Not  only  do  the  (jUinds  of  the  decidua 
hypertrophy,  but  the  interghiwhddr  .structure  as  well ;  and  in 
it  are  developed  large  epithelioid  cells,  known  as  decidual  cells. 

In  microscopic  sections  of  placenta  or  membranes  these  cells 
are  characteristic  of  decidual  tissue. 


Changes  in  the  Ovum;  Development  of  the  Foetus. 

The  impregnated  ovum  is  at  first  a  simple  cell. 
Its  wall  is  the  vitelline  meml)r(tne  ;  its  contents,  the  ffr<mul(ir 
vitellus,  or  j/olk,   and  a  nucleus;    which    latter  is  a  complex 


26 


PREGNANCY. 


structure  formed,  as  we  have  seen,  of  the  male  and  female 
pronuclei,  and  the  remains  of  the  germinal  vesicle. 

The  next  change  is  known  as  segmentation :  First  the 
nucleus  divides,  then  the  yolk,  tiius  formiiij^  two  complete 
cells  within  the  vitelline  memhrane.  These  two  cells  then 
divide  into  foiu',  these  four  into  eight,  and  so  on,  until  a  great 
nunjher  have  heen  formed  (Morula  stage;   Fig.  7). 


Diagram  showing  first  stages  of  segmentation  in  a  mammalian  ovum.    (Allen 

TiiompBon,  after  K.  van  Beneden.) 


The  first  divisior^  results  in  two  cells,  which  differ  somewhat 
both  in  size  and  appearance.  This  difference  is  perpetuated, 
so  that  as  a  result  of  their  further  division  two  groups  of  cells 
differing  in  size  and  appearance  are  formed. 

The  larger  are  termed  epiblast'iG  celh,  and  the  smaller  hypo- 
hlastic  cells. 

The  blastodermic  vesicle :  These  two  sets  of  cells  then  ar- 
range themselves  in  a  special  manner;  the  epiblastic  cells  com- 
pletely surrounding  the  hypoblastic  cells,  which  collect  in  a 


CHANGES  IN  OVUM;   DEVKlJtVMKNT  OF  F(ETUS.     27 

Fio.  8. 


li 


Two  further  stiiKCs  fi)llowin»,'  spjfmcntation  (niMiit's  ovum)  :  m,  cpiblHsf  ; 
Aj/,  hyjtoblust ;  /ij*,  opt'uing  in  epiblust  (blastoixire)  not  yet  closed  ;  in  II,  tliis  open- 
ing Ims  closed. 

rouglily  spherical  mass  (Fiji;.  8).  Between  these  two  layers  of 
cells  a  little  albiiniinous  fluid  begins  to  aecuniulate,  separating 
them  from  one  another  except  at  one  spot.     The  fluid  rapidly 

Fia.  9. 


zj>,  zona  pellucida;  ep,  epiblast ;  hy,  hypoblast;  b«,  cavity  of  blastodermic  vesicle. 


28  PREGNANCY. 

coUeots,  and  tlio  ovum  m  w  forms  a  (listeudcd  Vv  icle,  termed 
(lie  f)/(isf<)(lcnni('  vrnir/c. 

At  this  Htii^o  tli(!  cpiblastic  cells  completely  line  the  blasto- 
dermic vesicle,  while  the  mass  of  hypohlastie  cells  having 
becon)e  distended  by  the  accumulation  of  fluid  is  flatlencd  and 
pressed  out  over  c  small  area  of  the  epiblastic  cell-lining,  the 
central  portion  being  thicker  than  the  periphery  (Fig.  JM. 
This  thicker  |)art  is  tlie  commencement  of  the  embryonic  area. 

It  is  only  this  part  of  the  blastodermic  vesicle  which  is  con- 
cerned in  the  formation  of  the  embryo;  the  remaining  portion 
being  the  non-embryonic  part,  and  concerned  only  in  the  for- 
mation of  the  amnion  and  the  umbilical  vesicle,  as  we  shall  see 
lat(.'r. 

The  primitive  epiblastic  cells  peripheral  to  the  thickened  layer 
of  hypoblastic  cells  now  disappear,  leaving  tliis  portion  of  the 

Fig.  10. 


Transectidn  of  eiKhteen-hour  cliif'k  embryo,  showing  beginninp  of  medullary 
groove  and  the  three  layers:  a,  ectoderm;  b,  mesoderm;  c,  entoderm.  (Manton 
collection.) 

wall  (if  one  could  look,  as  it  were,  through  the  vitelline  mem- 
brane) somewhat  clearer  (area  pellucida). 

The  hypoblastic  cells  now  appear  as  a  darker  streak  in  the 
area  pellucida,  termed  the  primitive  streak;  which  then  devel- 
ops with  a  groove  known  as  the  primitive  groove,  which  is  t)ie 
first  evidence  of  the  formation  of  the  embryo,  indicating,  ap- 
proximately, the  position  of  the  future  vertebrae. 

Cleavage  of  the  hypoblastic  cells :  If  a  section  be  made  througii 
this  streak,  or  .^ove,  at  this  period  (Fig.  10),  the  hypoblastic 
cells  will  be  foiuid  to  have  separated  into  two  layers,  termed 
respectix'^ely  the  ectoderm  (permanent  epi blast)  and  the  ento- 


DKVKLOPMKyr  OF  TUI<:  MEM  BRAS  ES. 


29 


(hi'in  (pcriiiiiiicnt  li\  jxtMiist)  ;  wliiN-  Ix'lwccn  (liiMii  aiiotlu'r 
liivcr  i«:i->  tniiiud,  doiivcd  in  part  tV(»iii  both,  Icnnod  tlin  uhho- 
derm  (im'sohhist). 

Cleavage  of  the  mesoderm:  In  tlu'  coinsc  of  tinio  this  inoso- 
(lorin  develops  latend  redu|»iieiiti(>ns  and  divides  into  two  layers, 
tli(!  parietal  and  the  visceral  layers,  inrlosint:;  spaces.  The 
parietal  laver  unites  with  the;  cctoderni  to  form  the  Hoinato- 
j,/rnir ;  and  the  visceral  layer  unites  with  the  entoderm  to  lorin 
th(  xpfdiu'/niopkurc. 

'•:  ii'j  space  included  between  tlu*  two  leaves  of  the  deft  meso- 
derm is  the  primitive  hody-cavity,  or  c(elom,  which  afterward 
becomes  the  pIeiu'oj)eritoneal  cavity. 


Development  of  the  Membranes. 

The  amnion :  The  embryo  now  sinks  toward  the  centre  of 
the  ovum,  and  as   it  does  so  the  somatopleure  grows  up  all 


Fiu.  11. 


Fig.  12, 


/EiiihIatI 


Ki^r.  11.— //,  lit'iKl  (if  emhryn;  pp,  tnil-portinn  f)f  [)lonrnpcritoncal  onvity  ;  omr, 
t)iil-i)orti()ii  of  primitive  amniotic  cavity  (the  ;*/•/«*////>  Mmiiintic  ciivity  is  tlic  hollow 
space  inside  the  donble  folds  that  rise  over  the  hack  of  the  fcetus) ;  (U.f.,  tail-fold  of 
amnion;  nhf.  head-fold  of  amnion;  ,w,  sonintoplenre  ;  .v/>,  splanclinoiileiirc!  ;  rVr,  false 
amnion  ;  h>j,  hypoblast ;  at,  alimentary  canal,  coinninnicatintc  witii  cavity  of  nv,  the 
umbilical  vesicle;  ZP,  zona  pullucida;  A,  conunencinji  projection  of  alla'ntois. 

Fiff.  I'J.— The  amniotic  f()lds  have  united,  inclosing  hmcj,  the  trni'  amniotic 
cavity  :/a,  false  amnion,  whose  cavity  fnnr,f(mr./>,  iscrintinuons  with  the  ph-nroperito- 
neal  cavity;  (if,  alimentary  canal,  s"till  communicating  with  »r,  the  nmbilical  ves- 
icle ;  A,  sti'm  of  allantois  dilating  into  a  vesicle  at  x  ;  ////,  hypoblast ;  «;>,  sphmclino- 
pleure,  c(  nposed  of  mesoblast  and  hypoblast,  and  continuous  with  splanchnoplcure 
of  intestine  ;  ZP,  Mwa.  pollucida. 

around  it,   while  the  pplanchno])leure  sinks  with  it.      These 
somatopleuric  folds  thus  present    two   surfaces,  one    looking 


30  PRE3  NANCY. 

toward  tlie  embryo,  tlie  other  toward  tlie  outer  surface  of  tlie 
ovum  (Fig.  11). 

As  these  :'"oids  meet  over  tlie  back  of  the  embryo  they  coa- 
lesce, and  thus  fbru;  two  distinct  membranes  (Fig.  12).  The 
inner  membrane,  that  next  the  embryo,  forms  a  complete 
sac,  the  amniotic  .sac,  having  its  origin  close  to  the  cephalic;  and 
caudal  ends.  This  membrane  is  termed  the  amnion,  and  its 
inner  surface  is  derived  from  the  epiblast,  and  is  continuous 
with  the  skin  of  the  embryo,  which  is  also  epiblastic. 

The  outer  membrane,  which  has  its  outer  surface  composed 
of  epiblastic  cells,  then  retires  toward  the  outer  surface  of  the 
ovum,  to  form  the  chorion. 

Primitive  gut-  and  yolk-sac :  While  these  changes  are  in 
progress  in  the  somatopleure,  the  sj)lanchnopleure,  sinking 
toward  the  centre  of  the  ovum  along  with  the  embryo,  com- 
})letely  envelo})s  the  yolk.  By  bending  sharj)ly  inward  at  a 
point  some  distance  from  its  origin  the  splanchnopleure  forms 
a  second  canal,  which  is  thus  lined  with  liypoblast.  The  upper 
canal  eventually  becomes  the  fdinientary  tract;  while  the  lower 
is  the  yolk-sac  (Figs.  11-14).  This  latter  gradually  disappears, 
though  it  sometimes  persists  as  a  blind  sac  leading  from  the 
ileum,  known  as  Meckel's  diverticulum. 

The  allantois :  A  portion  of  the  splanchno])leure  forming  the 
wall  of  the  primitive  intestine  very  early  buds  outward,  projects 
into  the  pleuroperitoneal  cavity,  and  approaches  the  chorion. 
This  is  termed  the  allantois ;  in  its  sibstance  the  foetal  blood- 
vessels develop  (Figs.  11-14).  These  allantoic  bloodvessels 
line  the  chorion  and  dip  down  i^jto  the  villi. 

The  urachus  :  In  the  course  of  development,  that  part  of  the 
allantois  in  connection  with  the  body  becomes  obliterated.  A 
part  forms  the  urinary  bladder,  while  a  portion  of  it  persists 
as  a  fibrous  cord  running  from  this  viscus  to  the  umbilicus, 
termed  the  urachus. 

The  umbilical  cord :  Both  the  yolk-sac  and  the  allantois  are 
at  one  time  included  in  the  tube  formed  by  the  meeting  to- 
gether of  the  amnion  on  the  ventral  aspect  of  the  embryo, 
termed  the  abdominal  stalk,  which  becomes  the  umbilical  cord. 

The  chorion  is  the  permanent  outer  membrane  of  the  ovum, 
and  is  formed,  as  we  have  seen,  from  the  somatopleuric  layer, 
its  outer  surface  being  epiblastic  and  its  inner  mesoblastic. 


DEVELOPMENT  OF  THE  PLACENTA. 


31 


Tlie  wholo  superficial  area  of  tlie  chorion  soon  becomes  cov- 
ered with  littk'  projections,  termed  villi,  wiiich  *'  dip  down  "  into 
and  soon  become  attached  to  tiie  deeidna  (serotina  and  reHexa) 
at  all  points  of  contact. 

Each  villus  thus  has  an  outer  surface  of  epiblastic  tissue, 
while  its  core  is  formed  of  mesoblast.  The>«e  villi,  as  we  have 
seen,  receive  a  vascular  eq"oj)ment  from  the  allantois,  th()njj;h 
the  more  recent  view  is  that  the  capillaries  are  simply  formed 
from  the  mesoblastic  tissue  of  the  chorion.    Subsequently  those 


Fio.  13. 


Fi(i.  14. 


Fig.  13.— to,  true  amnion,  its  cavity,  amc.t,  bi'«iniiing  to  extend  witli  liquor 
anniii:/rt,  fiilso  amnion,  its  oavity,  (i»»r',  eontinuons  witli  iileiiroperitoneal  cavity; 
*'o.s,  folds  <if  true  amnion  bulging  over  abdomen  and  licginning  to  l'<jrm  slieatli  over 
stems  of  nmtjilieiil  vesicle  and  allantois;  »r,  umbilical  vesicle;  r;/,  zona  pellncida  ; 
A,  allantois;  its  stem  is  liollow  and  continuous  witli  cavity  of  alimentary  canal ;  at 
a- it  is  dilating  into  a  vesicle  line<l  with  liy|iob]ast. 

Fig.  11.— .1,  allantois,  its  cavity  miw  "obliterated,  it  lias  spread  all  around,  and 
joined  sub/oual  membrane  (comiiosed  of  false  amnion  and  vitelline  membrane) 
to  form  chorion;  iir,  remnant  of  undiilical  vesicle;  n/,  alinuntary  canal  ;  o,  dilated 
root  of  allantois  \\ithi!i  abdomen,  to  form  urinary  bladder  and  urachus  ;  in,  com 
menciug  infolding  uf  epihlast  to  J(Mti  cavity  of  alimentary  canal,  and  form  moutli 
and  bueeal  cavity  ;  a  .similar  notch  .  t  the  caudal  I'ud  of  the  embryo  indicates  site  <if 
future  anal  ojiem'ug  ;  .--v) .«,  folds  of  true  amnion  f<irmiiig  slu'atli  oi'  navel  string,  and 
inclosing  root  of  allantois  and  stem  of  umbilical  vesicle.  i,Tlie  other  letters  ba\i' 
same  reference  as  in  Fig.  Hi.) 

villi  in  contact  with  the  strotina  undcri]::o  rapid  development 
and  proliferation,  forming  the  chorion  \xn< J OHum  ;  wliile  those 
in  contact  with  the  reflexa,  termed  chorion  Iccve,  retrograde  and 
finally  atrophy. 


Development  of  the  Placenta. 

Structure:  The  placenta  is  chiefly  composed  of  ftrtal  tissue, 
the  chorion  frondosuni ;    but  the  superficial  layer  of  decidua 


's 


32 


PREGNANCY. 


scroti na  separates  with  it,  and  forms  its  maternal  surface. 
Thus  tlie  placenta  is  partly  f(X!tal  and  partly  maternal,  both  in 
origin  and  structure. 

The  villi  forming  the  chorion  frondosum  are  simply  tufts  of 
fcetal  capillaries  covered  with  two  or  more  layers  of  embryonal 
connective  tissue  dp"ived  from  t'  epiblast,  the  outermost  layer 
bemg  termed  the  syucitium  from  its  peculiar  phagocytic  func- 
tion. 

These  villi  branch  in  every  direction,  and,  coming  into  con- 
tacc  with  the  uneven  surface  of  the  decidua  serotina,  often 
appear  on  section  to  have  actually  dipped  down  into  it ;  bu+. 
this  is   only  apparent,   and  does  not  really  occur    (Fig.  15). 

Fig.  15. 


Scheme  of  idaeental  iittachmeiits :  Am,  aiiiiiion;  C/(,  chorion ;  r,  villi;  S, 
decidua  serotina:  Dsc.,  subchorionic  decidua:  Ij,  villi  attached  to  serotina;  A, 
maternal  artery ;   V,,  maternal  vein.    (After  Eden.) 

Tlie  maternal  capillaries  in  the  superficial  layer  of  the 
serotina  become  enormously  distended  with  blood,  thus  forming 
sinuses. 

Through  the  probable  ])hagocytic  action  of  the  syncitial 
masses  on  the  villi  the  superficial  layer  of  the  serotina  and  the 
walls  of  the  maternal  capillaries  are  in  time  ab.sorbed,  thus 
permitting  the  maternal  blood  to  escape  into  the  intervillous 
spaces. 


PLACENTA   AXD  MEMBRANES  AT  TEEM.  33 

Tlie  fu'tal  villi  are  then  in  direct  contact  with  the  maternal 
1,], >,,(!— are  loathed  in  it;  bnt  there  is  no  actual  connection 
Ix'tween  the  iu'tal  and  maternal  circulations,  as  tlie  walls  of 
the  lu'tal  villi  and  their  coverings  are  still  interposed. 

The  maternal  blood  is  carried  through  the  decidua  by  means 
of  spiral  twigs  derived  from  the  uterine  arteries ;  and  is  carried 
away  by  veins  having  an  oblique  direction  toward  the  perito- 
neal layer  of  the  uterus. 

This  formation  of  the  arteries  and  veins  in  the  decidua 
results  in  the  absolute  cutting  off  of  the  blood-supply,  when 
uterine  retraction  and  contraction  bring  about  the  expulsion 
of  the  placenta  at  birth. 

Placenta  and  Membranes  at  Term. 

a...'  placenta  at  tern^  -/.  c,  the  end  of  the  period  of  preg- 
nancv — is  a  soft,  spongy,  vascular  mass,  circular  in  outline, 
thi(  kest  at  its  centre,  where  the  umbilical  cord  is  inserted,  as  a 
rule,  rts  surface  is  six  to  nine  inches  in  diameter;  it  is  from 
one-half  to  one  and  one-half  inches  in  thickness;  and  weighs 
from  one  to  one  and  one-half  pounds. 

The  placenta  is  fully  formed  r.t  the  third  month,  though  its 
dimensions  increase  steadily  toward  term  and  bear  a  propor- 
tional relationship  to  the  size  of  the  child. 

There  are  two  aspects  of  the  placenta  to  be  described  :  first, 
the  fetid,  that  side  directed  toward  the  fa'tus;  secondly,  the 
maternal,  that  directed  toward  the  uterus. 

The  foBtal  aspect  of  the  placenta  is  covered  with  a  smooth 
shining  membrane,  which  is  continuwus  with  that  covering  the 
umbilical  cord  and  lining  the  amniotic  sac,  the  amnion. 
Beneath  this  may  be  seen  the  large  umbilical  vessels  running 
tortuously  on  the  chorion,  and  dividing  into  brandies,  which 
dip  down  at  right  angles  into  the  villi,  forming  the  mass  of  the 
placenta.  Deeper  down  the  darker  chorion  may  be  seen  through 
the  transparent  amnion.  The  remains  of  the  yolk-sac  may  occa- 
sionally be  noted,  looking  like  a  })iece  of  putty,  lying  a  short 
distance  from  the  insertion  of  the  cord. 

The  maternal  aspect  of  the  ])lacenta  is  of  a  dark  grayish-red 
hue,  and  is  divided  by  deep  sulci  into  lobules  of  irregular  out- 
line, termed  cotyledons.     Its  surface  is  covered  by  a  grayish, 

3— Obst. 


34  PREGNANCY. 

<;'listening,  tmusparent  membrane,  wliicli  is  the  maternal  por- 
tion of  tlie  placenta,  and  is  composed  of  the  superficial  layer 
of  the  decidua  serotina.  Therefore  tiie  line  of  cleavage,  when 
the  placenta  separates  from  the  uterine  wall,  is  through  the 
mubUe  or  S])ongy  layer  of  the  decidua. 

Around  the  periphery  of  the  placenta  runs  a  large  vein,  the 
circular  sinus  or  vein,  which  returns  a  portion  of  tlie  maternal 
hiood  from  the  organ. 

Tlie  site  of  the  placenta  in  the  uterus  varies,  though  it  is 
generally  on  the  anterior  or  on  the  posterior  wall. 

The  functions  of  the  placenta  are  many.  It  is  at  once  the 
lung,  the  alimentary  apparatus,  and  the  kidney  of  the  f(etus. 
In  it  the  fuetal  blood  parts  with  its  carbonic  acid  gas  and  its 
otiier  waste-products,  receiving  in  return,  from  the  maternal 
blood,  oxygen,  and  the  materials  necesFiuy  for  the  nutrition  of 
the  f(etus. 

The  epithelial  layers  of  the  chorionic  villi  seem  to  have 
certain  })owers  of  both  selection  and  resistance;  since  cer- 
tain bacilli  and  drugs  pass  readily  into  the  foetal  circuhition, 
while  others  do  not. 

The  umbilical  cord,  which  unites  the  fa^tus  with  the  placenta, 
is  formed  about  the  fourth  Mcek  of  gestation.  It  averages  at 
term  about  twenty  inches,  varying  from  four  to  eighty  inches, 
in  length.  Its  thickness  varies  from  the  size  of  the  little 
finger  to  that  of  the  tlunnb.  Its  sheath  is  composed  of  am- 
nion ;  it  contains  two  arteries  carrying  blood  from,  and  a  rein 
carrying  blood  /o,  the  foetus,  which  are  ind)eddcd  in  a  mucoid 
substance  known  as  Wharton^s  jelly.  Tiiese  vessels  run  in  a 
spiral  manner,  the  twists  usually  being  from  right  to  left. 

The  amnion  and  chorion,  with  the  slireddy  remains  of  the 
decidua  and  the  placenta,  when  they  are  examined  after  de- 
livery, are  seen  to  form  a  sac,  which  has  been  ruj)tured  at  one 
spot,  usually  at  the  site  of  the  internal  os,  to  permit  the  escape 
of  the  fcetus. 

The  decidua  on  the  membranes  is  somewhat  thicker  than 
that  on  the  maternal  aspect  of  the  placenta,  since  it  consists  of 
the  atrophied  reflexa  and  the  superficial  layer  of  the  vera.  It 
is  reddish  in  color  and  very  friable. 

The  chorion  can  be  readily  separated  from  the  amnion,  each 
of  these  forming  a  distinct  membrane  as  far  as  the  edge  of  the 


THE  OVUM  AT  DIFFERENT  PERIODS  OF  PREGNANCY.   35 

placenta.      The   cliorion  will   be  noted   to  be   thieker,    more 
opaque,  and  less  tough  than  the  amnion. 

The  amnion,  which  is  the  membrane  next  to  the  fciotus,  is  a 
clear,  translucent  membrane  whose  chief  characteristic  is  its 
tougiincss.  This  toughness  permits  tlie  sac,  when  distended 
with  liquor  amnii,  to  withstand  considcraMe  ])ressure,  and 
eiiabl(!s  the  bag  of  nuMubranes  to  act  in  an  ("flKcient  manner  as 
a  hvdrostatic  dilator  durinu;  the  first  staije  of  labor. 

The  liquor  amnii,  which  fills  the  amniotic  sac  and  in  which 
the  fietus  is  suspended,  is  a  light-colored  turbid  fluid  of  a 
specific  gravity  of  about  1010.  Its  quantity  varies  from  one 
to  two  pints  in  the  normal  state.  Its  source  is  not  (U'finitely 
known,  ^y  many  it  is  believed  to  exude  from  the  maternal 
vessels  in  the  uterine  walls,  but  it  is  ])robably  of  f<etal  origin. 

liii  fand'um  is  to  ])i*event  the  fcetus  being  pressetl  upon,  and 
to  allow  its  free  development.  Sho(;ks,  due  to  falls  or  l)lowson 
the  part  of  the  mother,  are  i)rcvcnl.  il  from  afFecting  the  fetus. 
During  labor,  as  has  been  said,  it  forms  the  most  perfect  di- 
lator of  tiie  cervix,  and  protects  the  child  from  the  great  press- 
ure brought  to  bear  on  the  uterine  contents  during  the  first 
stage  of  labor. 

The  Ovum  at  DiflFerent  Periods  of  Pregnancy. 

First  month:  At  the  end  of  the  fourth  week  the  ovum 
measures  about  1  inch  in  diameter,  and  the  straightened-out 
embryo  about  J  inch.  The  chorion  is  covered  with  villi,  and 
the  amnion  does  not  quite  fill  the  cavity  of  the  chorion,  the 
space  separating  them  containing  a  clear  fluid. 

Second  month:  At  the  end  of  this  month  the  ovum  is  nearlv 
2  inches  in  diameter,  and  the  embryo  f  inch  long.  The 
amnion  fills  the  chorion.  The  chorion  keve  is  atroph\Mn«,^  but 
the  cord  is  not  yet  twisted  and  contains  a  loop  of  intestine  at 
its  base. 

Third  month :  By  the  twelfth  week  the  ovum  is  4  inches 
in  the  long  diameter,  and  the  fcetus,  as  it  is  now  called,  is 
about  3^  inches  (7-9  cm.)  in  length.  The  placenta  is  com- 
pletely formed  and  the  rest  of  the  chorion  is  quite  free  from 
villi.  The  cord  is  twisted  and  the  loop  of  intestine  has  been 
withdrawn  into  the  abdominal  cavity. 


36  PREGNANCY. 

Fourth  month :  At  the  end  of  tlie  sixteenth  week  the  foetus 
nien-^nres  about  6  inches  (17  cm.)  in  length.  Tlie  liead  is  pro- 
por  "^Ily  very  large.  The  sex  can  be  distinguished.  Lanugo 
is],         t. 

Sixiii  month :  The  average  lengtii  of  the  ftetus  is  now  abt)ut 
12  inches  (28-34  cm.),  and  it  weighs  about  23 J  ounces  (G76 
gni.).     The  testicles  in  males  a.'c  still  in  the  abdominal  cavity. 

Seventh  month :  At  the  end  of  this  month  the  f(etus  meas- 
ures in  length  13.75  to  15  inches  (35-38  cm.),  and  weighs  41^ 
ounces  (1170  gm.).  The  whole  body  is  covered  with  lanugo, 
cxcej)t  the  palms  of  the  hands  and  the  soles  of  the  feet.  The 
pupillary  membrane  disappears. 

Eighth  month:  The  f(etus  now  measures  15  to  16  inches  (39 
to  41  cm.)  in  length  and  weighs  3 J  pounds  (1571  gm.)  Lanugo 
is  disa])pearing  from  the  face,  and  the  left  testicle  is  in  the 
scrotum.  Ossific  centres  are  present  in  the  lower  epiphyses  of 
the  femurs.     The  child  if  born  is  viable. 

Ninth  month:  At  the  end  of  this  month,  the  thirty-sixth 
week,  the  foetus  averages  about  5i-  pounds  in  weight.  At  this 
period,  if  the  infant  should  be  born.  Hirst  considers  that  with 
ordinary  care  it  should  certaiidy  live. 

The  consideration  of  the  infant  at  full  term,  the  fortieth 
week,  will  be  taken  up  under  the  heading  Labor  ;  but  it  is  con- 
venient at  this  point  to  refer  to  the  peculiarities  of  foetal  circu- 
lation. 

Foetal  Circulation  (Fig.  16). 

The  foetal  blood,  having  been  oxygenated  in  the  terminal 
villi  in  the  placenta,  is  returned  by  various  branches  to  the 
umbilical  vein.  This  is  carried  alono;  the  cord  to  the  f(ctal 
body,  which  it  enters  at  the  umbilicus.  It  runs  thence  along 
tlie  anterior  abdominal  wall  to  the  under  surface  of  the  liver, 
where  it  branches,  the  larger  branch  emptying  into  the  portal 
vein,  while  the  smaller,  called  the  ductus  venosus,  empties 
directly  into  the  ascending  vena  cava. 

Thus  the  largest  quantity  of  the  "  arterial "  blood  from  the 
])lacenta  must  pass  through  the  foetal  liver,  where  it  probably 
undergoes  some  changes  before  entering  the  general  circulation. 

Hence  is  poured  into  the  right  auricle  of  the  heart,  from  the 
ascending  vena  cava,  a  stream  of  blood  derived  from  (1)  the 


'£ui 


^ 


liKTAL   vni'^'LATlON. 


37 


Fio.  16. 


hopiitic  veins ;  (2)  tlie 
<hK'tns  vcnosus  ;  and  (3) 
tlio  lower  extremities  of 
the  tJetns  alont^  the  iliac 
rdna. 

This  mixed  stream  en- 
ters tl.e  rii2;iit  auricle  pos- 
teriorly, is  uuided  aeross 
it  l)va  ("old  of  memhrane, 
tciined  the  Eustachian 
valve,  throiitih  the  fora- 
men  ovale,  an  oj)eninL:;  in 
the  inter-anrienlar  se[»- 
tnm,  and  thus  enters  the 
left  anriclc. 

The  Knstaehian  valve, 
l)v  direetiny;  the  blood- 
eiH'rent  from  the  right 
ventricle,  thus  "short- 
circuits"  the  stream 
from  the  uudeveloj)ed 
tietal  lungs,  which  in 
their  unexpanded  con- 
dition could  not  contain 
such  a  large  quantity  of 
blood. 

From  the  left  auricle 
the  blood  enters  tlie  left 
ventricle,  passing  thence 

Diiiirrnin  uf  the  circnlntory 
(ii'i.'jiiis  of  the  tiuinaii  fii'tus  at 
six  iiKiiitlis:  /M.  rinlit  inirich'; 
AT,  riulit  v.'iitriclc;  LA,  k'ft 
aurii'lc:  Ev.  Iliistiicliian  Viilvo  ; 
/,.  liver:  A',  left  kidney;  /,  part 
(if  small  intcstiiu':  a,  aortic 
arch;  n',  its  ilursal  part;  n". 
iiosterior  end  of  abilomiiial 
aorta;  vex.  superior  vena  cava; 
vci,  inferior  vena  cava  near  its 
junction  witli  the  riirht  auricle;  rr/',  posterior  part  of  inferior  cava;  .«,  snhelavian 
vessels:  /,  riulit  Juiiular  vein  ;  c,  eonunon  carotid  arteries:  the  four  dotted  arrow- 
lines  iiuiicate  the  course  of  the  circulation:  '/o,  ductus  arteriosus:  an  arrow-line 
starting  at  vci  imlicates  the  course  of  hlood-flow  from  the  inferior  cava  through  the 
foramen  ovale  ;  lu\  hepatic  veins  ;  17),  vena  jiortrc;  .r  to  rci,  the  ductus  venosus  ;  uv, 
umbilical  vein ;  i(a,  umbilical  arteries  ;  uc,  umbilical  cord ;  i,  i,  iliac  vessels.  (Allen 
Thomson.) 


38  PREd  NANCY. 

to  the  aorta.  Tho  greater  ])art  of  the  stream  is  then  directed 
tliroiit^h  the  caroti  Is  to  tlie  head,  a  small  (juaiitity  only  eoii- 
timiiii;^  aioiijj:;  tiie  aorta. 

'I'hc  venous  blood  retnrniui^  from  the  head  is  collected  in  the 
descending  vena  cava,  and  j>assinn;  thence  into  the  right  auricle 
anteriorly,  it  finds  its  way  into  the  right  ventricle.  It  is  then 
forced  into  the  pulmonary  artery,  whence  it  [)asses  by  another 
"short  circuit,"  termed  the  ductus  arteriosus,  emptynig  into  the 
aorta  just  beyond  where  the  cai'otids  bi'anch  to  the  hea<l ;  only  a 
sutTicient  quantity  for  their  nutrition  being  directed  to  the  Udk/k. 

This  venous  blood  then  descends  along  the  aorta,  tin;  larger 
(juantity  ])assing  thence  to  the  iliac  arteries,  from  the  internal 
])air  of  whicih  two  arteries  pass  directly  to  the  umbilicus,  and 
thence  along  the  cord  to  the  placenta.  These  arteries  within 
the  body  are  termed  the  hypogastric  arteries. 

Thus  tlu^  lower  limbs  of  the  fJetus  receive  but  a  poor  supply 
of  what  is  practically  venous  blood  ;  hence  their  poor  develop- 
ment at  birth  as  compared  with  the  head,  which  receives  a  rich 
supj)ly  of  fairly  freshly  oxygenated  blood.  With  the  expan- 
sion of  the  lungs  at  birth  the  whole  course  of  the  circulation 
changes  to  that  which  persists  throughout  life. 

CHANGES  IN    THE    MATERNAL  ORGANISM  RESULTING 

FROM  PREGNANCY. 

Uter'ub. 

The  increase  in  the  size  of  the  uterus  takes  place  chiefly  in 
the  body  of  that  organ. 

The  cavlt}!  of  the  body  increases  in  length  from  11  inch(>s 
(''J.7  cm.)  ill  the  uii impregnated  state,  to  12  inches  (;}().o  cm.) ; 
the  width,  from  1]  inches  (3.2  cm)  to  9  inches  (23  cm.) ;  the 
dej)tli  (anteroposterior),  from  nothing  to  between  8  and  9 
inches  (20-23  cm.).  The  capacity  is  increased  from  nothing 
to  about  500  cubic  inches  (8300  c.cm.). 

The  weight  of  the  organ  increases  from  1  ounce  (30  gm.)  to 
about  24  ounces  (720  gm.). 

These  measurements  varv  with  the  size  of  the  foetus,  the 
quantity  of  liquor  amnii,  and  in  multiple  pregnancy. 

This  increase  in  size  is  a  growth,  and  not  a  mere  distention, 


UTERUS. 


l\\) 


for  ill  ectopic  o;cst;ition  tiu'  utcni.s  is  touml  to  go  on  grow i lit;,  up 
to  Mild  Ix'voiid  tli(>  ioiii'tii  iiioiitli. 

'J'lic  changes  in  shape  :iiv  clianu'tcristic.  In  tlic  noii-prc<:,- 
iiaiit  ('oiiditioii  the  uterus  is  pyrilonii,  tiie  large  end  being 
nppcniiost  ;  and  flattened  aiiteroposlerioriy. 

In  the  earlier  niuntiis  of  pregnancy  tiie  lower  part  seems  to 
increase  in  capacity  ta>ter  tiian  the  n|)per,  so  that  the  shaoe  of 
the  uterus  becomes  roughly  spherical  ;  wiiile  at  the  tit'ih  month, 
accordinir  to  Webster,  the  oruaii  is  once  more  ovrilbrm  in 
shajK',  but  the  wid(,'st  part  is  lowennost. 

At  the  end  of  ])re<'nancv  the  uleriis  assumes  verv  mtieji  the 
shape  of  tiie  non-pregnant  organ,  the  roomiest  part  being  again 
U[)permost. 

Thus  uj)  to  the  fifth  month  the  increase  in  the  capacity  of 
the  uterus  is  chiefly  in  its  lower  part;  and  from  tiien  till  term 
iiKiinly  in  its  nj)])er  portion. 

Muscle-fibres  :  The  marked  increase  in  the  bulk  of  the  ut<!rine 
wall  during  pregnancy  is  nu.inly  due  to  Iii/pcrlmphi/  of  the 
nii(fic/('-cc//s.  Ilelme  states  that  there  is  no  hvjun'plasia,  but 
that  the  existing  fibres  increase  from  seven  to  eleven  tinuvs  in 
length  and  from  three  to  five  times  in  breadth. 

The  arrangement  of  these  muscle-fibres  will  be  discussed 
later  under  tlu;  heading  of  aiuifonii/  of  labor. 

The  connective  tissue  of  the  uterus  increases  in  ]>roportion 
to  the  nuiscular.  There  exists  a  true  hyperplasia  of  the  con- 
nective tissue,  which  begins  in  the  neighborhood  of  the  blood- 
vessels. 

The  arteries  of  the  ut<M'us  become  markedly  increased  in 
calibre  and  length.  At  the  ])laeental  site  there  is  a  spiral 
arrangement  of  the  arterial  twigs,  as  they  penetrate  the  nterini; 
deeidua  and  empty  into  the  lacuuje.  The  veins  become  cor- 
resj)on(liiigly  incix-ased  in  size.  In  fact,  the  uterus  may  be 
regarded  as  a  huge  venous  plexus  during  pregnancy,  as  the 
blood-siip|)ly  is  so  great.  The  walls  of  these  veins  are  reduced 
to  the  iiitima,  so  that  after  labor  the  mere  contraction  of  the 
uterine  muscle-fibres  is  sufficient  to  obliterate  their  lumen. 

The  lymphatics  of  the  uterus  become  increased  both  by  hy- 
pertrophy and  hypcrpl.'isia.  Bcnieath  the  deeidua  enormous 
lymph-spaces  develo]),  the  tubes  or  vessels  leading  from  these 
to  the  lymphatic  plexus  beneath  the  peritoneal  layer  of  the 


40  PREGNANCY. 

uterus  rciicliiiifij  tlic  size  of  go().s('-(|ullls.  This  conditiciu  of 
the  uterine  lyinpliatic;  system  explains  tlu;  remaikaMy  rapid 
absorption  of  the  uterus  after  hihor,  as  well  as  that  of  septic 
material  from  the  utc^rine  cavity. 

The  nerves  of  the  uterus  take  part  in  the  jreueral  develoj)- 
ment,  the  increase  imu^  chiefly  in  the  primitive  sheath,  and 
not  in  the  nerve-substance. 

Th(!  ligaments  of  the  uterus  hypertrophy  din-ln<:;  pre<!:nan('y, 
and  their  relationshi[)s  become  altered  with  the  elevation  of 
the  fundus  in  the  abdominal  cavity. 

The  connective  tissue  throughout  the  pelvis  becomes  succu- 
lent and  distensible. 

Uterine  contractions  :  Throughoid  pretrnancy  the  uterus  is  in 
a  state  of  alternate  contraction  and  relaxation.  This  condition 
favors  the  circulation  of  the  maternal  blood  in  the  uterine  wall 
and  placental  sinuses.  These  contractions  may  be  noted  as  soon 
{IS  the  fundus  becomes  accessible  to  examination  from  the  ab- 
dominal surface. 

Relation  to  Pelvis  and  Abdomen. 

Up  to  the  third  month,  while  the  uterus  has  increased  in  size 
and  become  quite  globular  in  form,  its  level  in  the  pelvis  has 
undergone  no  marked  change.  It  has  become  somewhat  more 
anteflexed,  and  from  its  weight  has  sunk  down  somewhat  into 
the  j)elvis,  the  cervix  being  carried  backward,  so  that  on  mak- 
ing a  vaginal  examination  at  this  period,  the  anterior  uterine 
wall  can  be  readily  felt  and  seems  to  bulge  forward. 

By  the  end  of  the  third  month  the  fundus  uteri  has  risen  to 
the  brim  of  the  pelvis,  and  may  be  feU  n  moderately  deep 
pressure  just  above  the  symphysis  pubis 

By  the  end  of  the  fourth  month  the  fundus  is  in  contact  with 
the  anterior  abdominal  wall. 

At  the  sixth  month  it  reaches  the  level  of  the  umbilicus. 

At  the  seventh  month  it  is  half-way  between  the  umbilicus 
and  the  xiphoid  cartilage. 

At  the  ninth  month  it  is  up  to  the  level  of  the  lower  ribs  ; 
but  within  about  two  iceel-fi  of  labor  it  falls  forward  somewhat, 
and  seems  to  be  on  a  slightly  lower  level,  on  account  of  the 
descent  of  the  presenting  part  of  the  foetus  into  the  brim  of  the 
pelvis. 


^m 


('in\(;i':s  r.\  Tin-:  urf.asts. 


n 


Tlie  intestines  arc  «li>|)I:i('((l  upward  l)y  tlio  utonis  as  it 
asceiuls,  so  tliat  <ni  jHTciission  a  dull  note  is  uhtaiiicd  over  tlic 
wlioli!  (viitral  part  of  tlio  alxlomni. 

TluTo  is  a  ct'i'tain  amount  of  dextro-rotation  of  tiic  uterus 
I'ctaiucd  tlirouuliout  prc^uaucv,  so  that  tli<'  oriiau  leans  >ouie- 
wliat  to  the  rijiht  as  a  nde.  This  i-i<j;hl  obrK|uity  of  the  uterus 
niav  he  accounted  for  by  its  rehitioii  to  the  sigmoid  flexure  and 
(lesceiidintr  colon,  the  left  side  of  the  organ  being  i)ushed  for- 
wanl  bv  these  structures. 


Alterations  in  the  Cervix. 

Ther(>  are  two  conditions  of  the  cervix  during  pregnancy 
which  are  jwculiarly  characteristic.  B(»tii  are  diK'  to  a  partial 
obstruction  in  the;  venous  return  which  leads  to  softening  and  Ji 
marked  blue  or  violet  discoloration. 

The  softening  of  the  cervix  l)egins,  as  a  rule,  about  the  second 
month.  It  is  lirst  ai)parent  about  the  tip,  but  spreads  upward 
as  ])regnan(n'  advances,  so  that  in  the  later  months  the 
\vhol(!  cervix  becomes  so  soft  that  the  fingei",  if  unaccustomed 
to  vaginal  examination,  may  have  difliculty  in  finding  the  os 
uteri.  The  cervix  in  pregnancy  has  been  likened  in  feel  to 
that  of  the  ])outed  lips. 

The  violet  discoloration  is  due  simply  to  the  venous  engorge- 
ment, and  it  may  be  j^resent  even  in  the  first  few  weeks  of 
pregnancy.  The  canal  of  the  cervix  remains  throughout  preg- 
nancy unaltered  in  length.  Its  mucous  glands  secrete  a 
peculiarly  t(jugh  mucus,  wiiich  stops  up  the  canal  like  a  c(-rk 
throughout  pregnancy  (mucous  ping). 

Vagina,  Vulva,  and  Breasts. 

Tlie  vagina  and  vulva  become  somewliat  hypertrophied 
during  pregnancy.  The  color  of  the  mucous  memi)rane 
becomes  bluish.  There  is  a  slightly  increased  secretion  of 
nuicus,  and  the  parts  become  lax  and  soft. 

Changes  in  the  Breasts. 

With  the  onset  of  pregnancy  there  is  an  increased  deter- 
mination of  blood  to  the  breasts ;  and  certain  alteiations  pre- 
paratory to  the  function  of  lactation  begin. 


42 


ritl'JGXANCV. 


Tlit'sc  glands  attain  roinplctfi  (Nivclopiucnt  in  the  first  pro^- 
naiK'v. 

The  lobules  ciilarp'  and  liccoinc  distinct  tVoni  one  another. 

Tiie  epithelium  lining  tiu;  acini  h<'cunies  active,  kjadinjj;'  to  a 
certain  amount  of  desipianiation  of  th<'  nj>i»er  layers. 

These  cells  undei'ii'o  tatty  de<:;cneration  and  are  set  i'rec,  con- 
st it  ntint;  colostrum-corpuscles. 

Very  early  in  pregnancy  a  small  quantity  of  serum  may  he 
expressed  from  the  nij)ples. 

The  fat  and  connective  tissue  snrroimdinji  the  lobules  hyper- 
trtiphy,  and  the  hreasts  l)eet)n>(!  eidar<;('d  and  more  prominent. 

Coincident  with  these  ehauj^es  there  is  increased  tenderness 
on  pressure. 

The  skin  heconies  stretchecl  and  striie  develop,  havin'j;  a 
radial  disti'ihution  and  diicction.  The  veins  on  the  surface 
b(>come  more  obvious. 

The  areola  becomes  darker  from  dejMisit  of  j)igment,  this 
being  more  marked  in  brunettes  than  in  blondes  (Fig.  17). 

Fio.  17. 


-17- 

'■■:,:h..Ji^ 

■*.^^£.!^ 

^B^^^t;  '■ 

■mm 

■'■■fmm 

w 

y,;^ 

IP- 

|si.^ 

-3^ 

''"w.'ntrtl 

— i 

•^         1 

Brunette:  Wrinkling  of  iiriniary  areola;  x.  ,1.,  well-defined  secondary  aroula. 

(Itii'kinson.) 

The  ftchaccous  fnUiclr.'^  of  the  areola,  ton  or  twenty  in  num- 
ber, become  more  prominent,  being  of  lighter  color.  These 
follicles  at  the  margin  of  the  areola  licing  uncolored,  stand  out 
prominently  as  white  spots,  forming  the  so-called  secondary 
areola. 

The  nipples  become  more  prominent  as  a  rule,  and  are  softer 


ALTKIiATIONS  IS  OTUKR  THAN  GKNICIiATlVJJ  ORCiASii    43 


than  ill  tlie  n<»n-j)i('p;iiaiit  state.  In  tlio  later  inontlis  of  pre^- 
naiKy  dried  cakes  (if  secretion  may  be  found  encrusted  on  tlieir 
surface. 

Alterations  in  Other  than  the  Generative  Organs. 

Nervous  system:  'I'lien;  is  present  durin<:;  prej^iiaucy  a  condi- 
tion of  cvidfrd  in'rrr-tciisioii.  Hence  there  is  an  increased 
tendency  to  nervous  instability.  The  woman  is  more  prone  to 
hysterical  attacks.  There  are  often  present  juMversions  of  taste, 
smell,  etc.  ;  also  neuralgia,  especially  of  the  face  and  teeth. 
Mental  affections  are  apt  to  develop  during  this  period. 

This  condition  of  increased  nerve-tension  causes  about  two- 
thirds  of  all  pregnant  women  to  suller  from  vomUin<j  at  s(mic 
til    '  or  another  of  their  pregnancy. 

This  so-called  voin'd'nuj  of  pirgnancy  begins,  in  a  largo  ma- 
jority of  cases,  early  in  the  second  month  ;  it  usually  persists 
during  the  second  and  third  months,  but  may  last  throughout 
pregnancy.  It  may  be;  looked  upon  as  one  of  the  symj)toms  of 
the  pregnant  condition. 

It  usually  occurs  on  first  rising  in  the  morning,  and  may  be 
mild  or  sufficiently  severe  to  endanger  the  woman's  life. 

The  essential  cvcit in (/  cause  oi'  tha  vomiting  probably  origin- 
ates in  the  physiological  uterine  contractions  occurring  through- 
out pregnancy  (see  Pernicious  VomitiiKj). 

Circulatory  system  :  The  total  quantity  of  blood  is  increased. 
The  quality  is  also  changed,  there  being  an  increase  in  fibrin 
and  white  corpuscles;  while  the  red  ccpuseles  and  albumin 
are  diminished. 

The  hcdrt,  probably  as  a  result  of  the  chang'^s  in  blood 
(juality,  undergoes  some  dihdation  ;  but  as  the  quantitv  of  the 
blood  is  increased  there  is  a  perfectly  comi»ens(itory  lijiperlrojdijf 
which  is  more  marked  on  the  left  side.  Both  spleen  and  tlii/roid 
(jlcnid  increase  in  size. 

Respiratory  system  :  As  the  rango  of  movement  of  the  dia- 
})hragm  bet;omes  interfered  with  by  the  uterus  the  thorax 
widens  to  a  slight  extent.  Owing  to  increased  oxidation-proc- 
esses, the  work  of  the  lungs  is  augmented. 

There  is  but  little  change  in  the  alimentary  system.  The 
digestive  processes  are  somewhat  more  active,  and,  as  a  rule, 
the  appetite  is  increased.     Digestive  disturbance  is  common. 


44  PREGNANCY. 

Urinary  system :  Tlie  uriiu^  is  iiicreascsd  in  quantity  and  is 
more  watery,  the  specific  gravity  bein^-  about  1014.  The 
quantity  of  lu'ea  excreted  is  normal. 

Cutaneous  system :  The  liinctions  ol"  the  skin  are  increased 
during  pregnancy. 

J*i(/iii<nif((ti()ii  is  increased.  Then;  is,  as  a  rule,  a  marivcd 
deposit  of  j)igment  over  the  linea  alba,  so  nuicii  so  as  to  con- 
stitute one  of  th(>  signs  of  pregnancy;  it  may  reach  from  the 
pubes  to  tJie  ensifoi-m  cartilage.  The  skin  around  the  eyes  is 
darkened,  and  frequently  irregular  s[)ots  of  pigment  aj)pcar  on 
the  surface  of  the  body,  chiefly  in  the  face. 

Linese  albicantes :  Certain  skin-cracks  are  to  be  noticed, 
chicHy  as  a  result  of  ON'cr-stretching.  They  are  termed  Ktri(r, 
H)ic(v  (ifhicdufci^,  linar  inafcvi><r,  or  Ihicni  (jraridnrunt,  and  appear 
usually  on  the  skin  of  the  abdomen  and  breasts.  They  run 
usually  in  the  lines  of  tension,  and  are  due  to  yielding  of  the 
corium  in  stretching,  the  epidermis  being  continuous  over  them 
without  any  change  in  structure.  They  vary  in  length  up  to 
two  or  more  inches,  and  when  recent  are  red  in  color.  Later 
on,  as  a  result  of  scar-formation,  they  becom(>  white,  and  form 
strong  presumptive  evidence  when  present  of  previous  preg- 
nancv. 

DURATION;    DIAGNOSIS;    HYGIENE    AND   MANAGE- 
MENT   OF  PREGNANCY. 

Duration  of  Pregnancy. 

As  a  rule,  it  is  impossible  to  predict  exactly  the  date  \\]wn 
labor  will  take  place. 

If  the  date  of  fruitful  coitus  can  be  fixed,  then  labor  will 
most  likely  set  in  two  hundred  and  seventy-one  days  later, 
according  to  Ahlfeld. 

The  common  rule  is  that  labor  will  occur  on  the  day  of  the 
tenth  menstrual  period — /.  c,  two  hundred  and  eighty  days 
after  the  first  day  of  the  last  menstruation.  Allowance  must 
always  be  made  for  the  short  month  February. 

As  a  rule,  one  seldom  predicts  the  exact  day  of  labor,  and  the 
variation  of  a  week  or  two  is  far  from  common. 

When  pregnancy  occurs  during  a  period  of  amenorrhoea,  as 


FIRST  TRIMESTER— SUBJECTIVE  SYMPTOMS. 


45 


lactation;  or  if  the  date  of  the  last  iiionstniation  cannot  lie 
ascertained,  then  th(^  probable  tlato  of  labor  may  be  fixed  by 
noting  the  height  of  the  fundus : 

The  .tollowint;'  table  has  been  giv  n  by  >Satugin  and  Galabin  : 


Weeks 
Inches 
Cm.    . 


16 

4 

10 


t>0 
5.4 
13.0 


04 

*- * 

28 

32 

34 

36 

38 

6.0 

7.S 

8.7 

9 

9.3 

9.6 

16.5 

li».5 

22 

23 

23.5 

24     S 

40 
10 


Tiiis  method  can  oidy  be  employed  in  cases  M'here  the  head 
pr(>.sents  at  the  brim  of  the  ])elvis.  Tiie  vicd.sKrcmenf  is  made 
bv  placing  one  tij)  of  a  pair  of  calipers  on  the  syniphysi.s  pnbis 
and  the  other  on  the  fundns  nteri. 

The  date  of  quickening — /.  c,  the  first  occasion  on  whicli  the 
mother  feels  the  mov(!ments  of  the  fcetus — is  of  .some  value  in 
estimating  tlu;  dnration  of  pregnancy.  Quickening  occurs  in 
the  twentieth  week  as  a  rule  in  jn'imipara*;  and  in  the  twenty- 
first  or  twenty-.secoud  week  in  multipane. 

Diagnosis  of  Pregnancy. 

The  recognition  of  pregnancy  is  not  always  an  easy  matter, 
especially  in  tlu!  earlier  months  of  gestation. 

Careful,  systematic,  and,  if  necessary,  rej)eated  examination 
camiot  fail  to  j)ermit  a  certain  diagnosis  being  made. 

Failure  in  diagnosis  is  nearly  always  the  result  of  careless 
and  unsystematic  examination. 

For  convenience  of  study  the  nine  calendar  montli.s  of  j)reg- 
nancy  may  be  divided  into  trimcsfn-fi ;  and  a  classification  of 
the  symptoms  and  signs  as  to  these  three  periods  be  made. 

First  Trimester — Subjective  Symptoms. 

The  suppression  of  menstruation  constitutes,  as  a  rule,  the 
first  evidence  of  pregnancy.  This  function  is  usually  su.s- 
])ended  throughout  gestation  ;  but  this  is  not  invariable.  Some 
women  menstruate  at  least  once,  and  occasionally  several  times 
after  the  occurrence  of  pregnancy.  The  value  of  this  sign  as 
evidence  is  less  in  women  who  are  very  irregular  in  menstru- 
ating. 

Cavfies:    Suppression  may  result   from    exposure   to   cold; 


46  PREGNANCY. 

from  the  presence  of  debilitating  disease,  as  tuberculosis, 
anaemia,  etc. ;  over-anxiety  or  marked  fear  of  pregnancy  may 
produce  this  result,  as  may  also  sudden  mental  shock  ;  change 
of  climate  or  surroundings  occasionally  act  in  the  same  way. 
These  exceptions  should  be  held  in  mind ;  but  suppression  of 
menstruation  in  a  healthy  woman  of  regular  habit  usually 
means  })rcgnancy. 

Nausea  and  vomiting,  occurring  in  the  morning  especially, 
form  one  of  the  most  common  symptoms  of  pregnancy. 

The  sensation  usually  comes  on  when  the  woman  fir^t  as- 
sumes the  erect  position  in  the  morning,  hence  the  term  "  morn- 
iny  .sickness  "  commonly  a})plied  to  it. 

These  sym})toms,  as  a  rule,  appear  in  the  fourth  or  fifth  week  ; 
but  may  occur  even  earlier.  They  cease,  as  a  rule,  about  the 
fourth  month  ;  but  may  persist  throughout  pregnancy.  The 
causation  has  already  been  referred  to. 

The  mammary  changes  l)egin  as  early  as  the  second  month, 
the  congestion  of  the  parts  causing  a  sensation  of  fulness,  with 
tingling  and  tenderness.  Increase  of  pigmentation  about  the 
areolae  and  the  presence  of  serum  in  the  lacteal  ducts  become 
apparent  during  the  third  month. 

Vesical  irrit.  lion  is  often  complained  of  very  early  in  preg- 
nancy. As  a  result  of  the  increase  in  the  normal  anteversion 
of  the  uterus,  the  bladder  is  pressed  upon  and  its  functions  in- 
terfered with  ;  this  usually  persists  till  the  fourth  month. 

Frequently  digestive  disturbances  arise  early  in  pregnancy, 
having  a  reflex  origin.  The  appetite  becomes  capricious,  and 
ncidity  is  common. 

Nervous  disorders,  which  are  purely  functional,  are  not  infre- 
(Tjuent.  Ptyalism  is  not  uncommon,  and  may  persist  throughout 
gestation.  Neuralgias,  cardiac  disturbances,  mental  perturba- 
tio;.  and  irritability  frequently  manifest  themselves  very  early 
and  are  oftc:^  very  persistent. 

First  Trimester — Objective  Signs. 

These  are  confined  chiefly  to  the  uterus  and  the  breasts. 

The  softening  of  the  cervix  uteri  begins  in  the  first  month 
of  pregnancy.  The  whole  cervix,  beginning  first  at  the  external 
OS,  gradually  softens  as  a  result  of  the  physiological  uterine 


FIRST  TRIMESTER— OIUKCTIVK  SIUSS. 


47 


congestion.  This  change  is  most  marked  in  the  primipara, 
but  is  also  present  in  the  multipara.  The  cervix  becomes 
plugged  with  nnurus  as  a  result  of  the  increase  in  the  activity 
of  the  cervical  mucous  membrane. 

A  violet  discoloration  of  the  mucous  membrane  of  the 
cervix,  vagina,  and  vulva  may  be  noted  on  insj»cction  of  these 
parts,  beginning  as  early  as  the  fiftli  week  in  many  cases, 
i'liis  discoloration,  being  due  to  a  certain  <lcgree  of  venous 
stasis,  becomes  more  marked  as  pregnancy  advances;  it  shades 
from  a  ])ale  violet  tinge  to  a  dusky  blui>h  hue. 

Tiie  softening  and  enlargement  of  the  body  of  the  uterus 
consequent  upon  pregnancy  may  b(!  readily  made  out  by  care- 
ful combined  examination.  JI(y<ir\s  si(/)t  (see  below)  of  early 
pregnancy  de[)ends  upon  the  [)resence  of  these  elianges,  and 
may  be  obtained  as  early  as  the  eighth  week.  As  a  result  of 
the  presence  of  the  ovum  in  the  upper  segment  of  the  uterus, 
all  the  diameters  of  the  latter  become  increased,  while  the 
cinj)ty  lower  segment  simply  becomes  softened  and  perhaps 
lather  thinned  out. 

On  bimanual  examination  the  bulky,  |)artly  softened  cervix 
can  be  felt ;  just  above  this  is  a  very  soft  compressible  area ;  and 

Vui.  18. 


resilient 


Paring 
contraction 


CliaiiKL's  ill  the  invguaiit  uiitus  .if  tlic  sixtli  wrck  :  mi  tlic  Ifft  wlu'ii  a-laxed,  on  the 
rislit  wlKii  contnictiiiK.     (Diekinsdn.) 

above  this  again  the  boggy  rounded  fundus  uteri  may  be  dis- 
tinguished (Fig.  18).     The  sensation  conveyed  to  the  exam- 


4 


48 


PREGNANCY. 


iner's  finger  is  that  tlie  cervix  is  joined  to  the  body  of  the 
uterus  by  two  longitudinal  bands  (Hcffar's  f^if/n).  This  is 
best  obtained  by  placing  the  thumb  of  the  right  hand  in  the 
anterior  vaginal  fornix  and  introducing  the  forefinger  of  the 
same  hand  into  the  rectum,  then  the  left  hand  placed  over  the 
pubis  presses   the    uterus  downward  so  that  the  cervix  and 

Fig.  19. 


Bimanual  cxaiiiiuation  I'urcomprcssihility  of  tlie  isthmus  at  the  sixth  week. 

(Diolcinson.) 

lower  part  of  the  body  may  be  grasped  between  the  thumb 
and  forefinger  of  the  right  hand  ;  or  as  shown  in  Fig.  19. 

In  the  third  month  the  body  of  the  uterus  is  felt  to  be  en- 
larged and  rounded  as  well  as  softened  ;  while  tlie  whole  organ, 
which  pretty  well  fills  the  pelvic  cavity,  is  in  a  position  of 
marked  anteversioii  as  a  rule. 


Second  Trimester. 


In  this  period  the  subjective  symptoms  are :  (1)  continued 
absence  of  menses;  (2)  the  passing  away  of  the  troublesome 
nausea  and  vesical  irritation ;  (3)  the  sensation  of  "  quicken- 
ing " — i.  e.,  foetal  movement. 


SECOND   TRIMESTEP.  49 

The  objective  signs  arc:  (1)  enlargement  of  the  abdomen; 
(2)  progressive  t-liangcs  in  tlie  mainina? ;  (3)  progressive 
chnngos  in  tlie  nterus ;  (4)  i\w  J'nliiif/  of  uterine  eontreiciiom 
and  of  the  f(vt((l  moveinenh  by  tlie  examiner ;  (5)  auscn(t<itlon 
oi'  fnial  heart-sounds ;  (())  Ixtllottement. 

in  tlie  fonrth  month  the  fnndns  becomes  easily  accessible 
from  the  anterior  al)dt)minal  wall;  hence  at  this  period  for  the 
iirst  time  may  be  felt  the  irregular  intermittent  uterine  contrac- 
tions which  continue  throughout  pregnancy.  These  contrac- 
tions take  place  at  intervals  of  from  ten  to  twenty  minutes,  and 
lead  to  marked  hardening  of  the  whole  uterine  tumor. 

Fcetal  movements,  or  quickening,  are  usually  first  noticed 
by  the  mother  about  the  twentieth  week.  As  pregnancy  ad- 
vances these  movements  become  more  marked  and  constant, 
and  may  be  best  obtained  by  the  physician  by  suddenly  placing 
his  cold  hand  on  the  mother's  abdomen  over  the  uterus. 

On  auscultation  a  loud  bruit  may  l)e  heard  over  some  portion 
of  the  uterus  as  early  as  the  fourth  month.  This  sound  has 
Ix'cn  termed  the  "  uterine  souffle."  It  is  synchronous  with  the 
maternal  pulse,  and  is  very  uncertain  in  its  duration  and  place. 
It  is  heard  not  only  during  ])regnancy,  but  it  is  occasionally 
assciated  with  the  presence  of  interstitial  fibroirls  and  with  ova- 
rian tumors. 

The  fcetal  heart-sounds  may  be  heard  as  early  as  the  twen- 
tieth week  by  skilled  examiners.  They  are  heard  best  while 
the  patient  is  in  the  dorsal  position  with  the  abdominal  wall 
relaxed,  and  with  the  bell  of  the  stethoscope  resting  lightly  in 
contact  with  it.  If  pressure  be  made  on  the  bell,  or  even  if  it 
be  held  in  place  by  the  hand,  the  sounds  cannot  be  heard  so 
well. 

The  rate  of  pulsation  varies  from  120  to  150  per  minute, 
being  slower  in  males  than  in  females.  The  sounds  are 
double,  the  first  being  somewhat  clearer  than  the  second.  The 
sounds  of  the  fa^tal  heart  have  been  very  aptly  compared  to 
those  of  a  watch  ticking  under  a  pillow.  The  firtal  heart- 
sounds  bear  no  relation  to,  and  are  quite  distinct  from,  the 
maternal  pulsations. 

By  the  sixth  month,  the  fundus  having  reached  the  level  of 
the  umbilicus,  which  has  become  flattened  out,  the  abdomen  has 
become  quite  prominent. 

4— Obst. 


60 


PREGNANCY. 


At  this  time  also  a  brownish  pigmentation  may  be  noted  ex- 
tending from  the  pubes  up  to  and  beyond  tiie  umbilicus. 

Ballottement,  one  of  the  most  valuable  signs  of  pregnamy, 
becomes  available  late  in  tiie  fourth  month.  It  is  a  passive 
movement  of  the  foetus  obtained  by  its  sudden  displacement 
from  below  by  the  examiner  (Fig.  20).     While  placing  tiic 

Fio.  20. 


M'^WMWBMMWIMw.MJi  iiiliiii      •  f  ny 


Internal  ballottement,  semi-recumbent  posture,  at  sixth  month.    (Dickinson.) 

forefinger  of  the  right  hand  in  the  anterior  vaginal  fornix, 
one  may  by  a  brisk  impulse  displace  the  foetus  upward,  which, 
as  it  resumes  its  original  position,  conveys  a  gentle  tap  to  the 
finger-tip  held  in  the  vagina.  Ballottement  can  only  be  simu- 
hited  by  a  small  cystic  ovarian  tumor  having  a  long  pedicle. 

Third  Trimester. 

The  subjective  symptoms  in  this  period  are :  (1)  continued 
absence  of  menstruation ;  (2)  foetal  movements ;  (3)  pressure- 
symptoms. 


^*f!?I!^, 


SUMMARY  OF  DIAGNOSIS.  61 

The  objective  signs  are:  (1)  continued  enlargement  of  the 
abdomen;  (2)  continued  mammarv  and  uterine  ciianges ;  (3) 
development  of  .strise  on  abdomen  and  breasts. 

Owing  to  tiie  great  enlargement  of  the  uterus  pressure-symp- 
toms become  very  marked  in  many  cases.  I'ttriccs  of  the  lower 
limbs  and  vulva,  often  accompanied  by  (r<lnit((,  become  more 
or  less  marked.  (Jonaiipaiion  from  pressure  on  the  rectum, 
and  rcHical  irritation  from  displacement  of  the  bladder  ui)\vard, 
are  common. 

J>i.stnrh(niccfi  of  difjcstion  and  of  rcKpiration  are  common,  both 
resulting  from  the  great  abdominal  distention. 

The  movements  of  the  foetus  can  be  plainly  seen  through  the 
abdominal  wall. 

The  skin  on  the  abdomen  frequently  shows  linear  markings, 
which  apj)ear  as  red  radiating  striae,  chiefly  on  the  lower  quad- 
rants. 

The  umbilicus  becomes  prominent,  and  there  is  an  increase  in 
the  deposit  of  pigment  in  the  middle  line. 

"  Settling  "  :  Within  two  weeks  of  labor  the  presenting  ])art 
of  the  foetus  partially  enters  the  brim  of  the  pelvis,  becoming 
more  accessible  to  the  examining  finger.  The  cervix  also  be- 
comes somewhat  thimied  out  and  feels  shortened.  At  this  tiine 
the  prominence  of  the  abdomen  becomes  less  marked. 

To  these  changes  occurring  in  the  last  two  weeks  prepara- 
tory to  labor  the  term  ".sv/////k/"  has  been  a})[)lie(l. 

The  mammary  changes  continue  to  become  more  marked,  and 
colostrum  can  be  expressed  from  the  nipples. 

Summary  of  Diagnosis. 

The  presumptive  evidences  of  pregnancy  are:  (1)  menstrual 
suppression;  (2)  morning  sickness;  (3)  irritable  bladder;  (4) 
mental  and  emotional  phenomena. 

The  probable  evidences  are :  (1)  manmiary  changes ;  (2) 
abdominal  changes  (e.g.,  size,  shape,  markings);  (3)  uterine 
changes  (size,  shape,  color,  and  consistency  of  cervix) ;  (4) 
uterine  contractions  and  bruit. 

The  only  positive  signs  tire  f(etal:  (1)  foetal  heart-sounds; 
(2)  foetal  movements ;  (3)  ballottement. 


52  PREGNANCY. 

Differential  Diagnosis  of  Pregnancy. 

The  pliysician  is  not  infrequently  called  upon  to  make  an 
examination  wliere  the  patient  either  feigns,  desires,  or,  more 
commonly,  conceals  the  condition  of  pregnancy.  The  diffi- 
culties of  diagnosis  are  much  greater  before  the  fourth  month 
of  gestation  ;  but  careful  systematic  examination  will  scarcely 
fail  to  establish  a  certainty  in  the  majority  of  cases.  Care 
nnist  be  taken  not  to  express  an  opinion  until  a  reasonable  cer- 
tainty of  the  condition  p.eseut  is  obtained. 

First  Trimester. 

In  this  period  the  following  conditions  may  resemble  preg- 
nancy :  amenorrhooa  ;  subinvolution  ;  metritis  ;  uterine  fibroid  ; 
retained  menses;  malignant  disease;  tumors  in  the  neighbor- 
hood of  the  uterus,  as  ovarian  growths;  salpingitis  ;  and  ectopic 
gestation. 

Simple  amenorrhoea  accompanied  by  symptoms  of  gastric 
irritatit)n  may  very  closely  resemble  pregnancy  ;  but  a  careful 
bimanual  examination  will  demonstrate  the  absence  of  uterine 
changes. 

In  subinvolution  the  uterus  does  not  increase  in  size,  and  it 
is  not  globular ;  while  its  texture  is  harder  than  that  of  the 
organ  in  jiregnancy. 

In  metritis  the  uterus,  while  enlarged,  is  sensitive  to  the 
touch,  and  is  hard  and  dense.  Its  shape  is  that  of  the  unini- 
pregnated  organ  simply  increased  in  size. 

An  interstitial  fibroid  of  the  uterus  may  be  distinguished  by 
its  denseness  and  by  the  irregular  contour.  Menstruation,  in- 
stead of  being  absent,  is,  as  a  rule,  increased. 

Retained  menses  may  cause  an  enlargement  of  the  uterus; 
but  in  such  cases  the  fact  that  menstruation  has  never  been 
established,  and  a  history  of  abdominal  pains  occurring  at 
monthly  intervals,  will  indicate  the  nature  of  the  case. 

In  malignant  disease  of  the  uterus  the  menstruation  is,  as  a 
rule,  increased,  and  intermenstrual  hemorrhages  occur. 

In  ovarian  tumors  the  uterus  is  not  affected  and  menstrua- 
tion persists  as  a  rule.  The  tumor  is  usually  situated  to  one 
side  of  the  uterus  and  causes  some  displacement  of  that  organ. 


■^ 


DIAGNOSIS  OF  VAIUTY  OR  NULLirARlTY.  53 

Ectopic  gestation  may  simulate  uterino  pivj^iiancy ;  but  caro- 
ful  c'xauiiiialiuu  will  ivvoal  tlio  pivsonce  ul'  a  tuuior  outside 
the  uterus. 

In  the  Later  Months  of  Pregnancy 

the  I'olluwino;  conditions  may  load  to  an  error  of  diai^nosis  : 
(.JM'sity,  ascites,  tympanites,  phantom  tumor,  and  lar<>,e  ovarian 
or  fibroid  tumors. 

\\\  obese  women  with  irregular  menstruation  it  is  not  infre- 
<|iicutly  dillieult  to  establish  a  diagnosis  of  pregnancy  ;  but  the 
absence  of  mammary  changes  and  auscultatory  signs  will  clear 
up  the  case. 

In  ascites  a  diagnosis  may  I)e  made  by  j)lacing  the  patient  in 
the  dorsal  decubitus  and  percussing  the  abdomen.  Both  Hanks 
will  give  a  dull  note,  while  tlie  middle  area  of  the  abdomen 
will  be  clear.  Fluctuation  may  be  obtained  ;  and  on  changing 
the  })osition  of  tlu;  |)atient  the  area  of  dulness  will  alter. 

In  tympanites,  the  whole  abdomen,  while  enlarged,  gives  a 
clear  note  on  percussion.  The  bimanual  examination  in  both 
the  above  conditions  will  reveal  the  unimpregnated  condition 
(»f  the  uterus. 

Phantom  tumors,  which  are  occasionally  met  with  in  hysteri- 
cal women,  can  be  recognized  on  applying  the  usual  tests  of 
auscultation,  pi'rcussion,  etc. 

Pseudocyesis,  or  spurious  pirf/iKinci/,  is  a  very  interesting 
condition  met  with  usually  in  women  about  tbe  time  of  the 
menoj)ause.  The  woman  imagines  herself  tt)  be  pregnant,  and 
develops  many  of  the  characteristic  symptoms  of  that  condi- 
tion. Eidargement  of  the  abdomen,  fulness  and  tenderness  of 
the  breasts,  may  mislead  the  careless  examiner;  but  in  both 
the  above  classes  of  cases  tbe  administration  of  an  aniesthetic,  to 
permit  of  a  thorough  examination,  will  clear  up  the  diagnosis. 

Ovarian  and  fibroid  tumors,  if  large,  may  cause  distention  of 
the  abdomen  ;  but  in  these  cases  the  absence  of  all  signs  of  a 
Hetus  will  suflice  to  (bstiuguish  the  conditions  from  pregnancy. 

Diagnosis  of  Parity  or  Nulliparity. 

Certain  mechanical  effects  are  produced  on  the  abdominal 
wall  and  birth-canal  of  a  woman  who  has  previously  borne  a 


64  PRIX!  NANCY. 

f'lill-tcnii  child,  wliicli  timc!  fjiils  quite  to  eradicate.  On  these 
depends  the  di;i<2;iiosis  of  parity  or  iiulli|)!irity. 

If  tlie  ovum  has  heeii  discliarf^ed  befon;  it  was  siifhcioiitly 
hirnc!  to  pro(hu'e  those  changes,  tlieii  it  is  j)ractically  impossible 
to  be  certain  as  to  parity. 

These  signs  consist  of  changes  in  the  breasts,  perinenm, 
vagina,  and  cervix,  as  well  as  laxity  and  strise  of  the  abdom- 
inal wall. 

In  the  parous  woman  the  hrcadu  are  a|)t  to  be  well  developed 
a. id  somewhat  pendulous,  the  ni])ples  being  large  and  promi- 
lujiit.     Occasionally  striiemay  be  noticed. 

The  (ifxIoiiiiiKif  vuill  is  lax  and  yielding,  the  skin  being 
marked  with   white  strije. 

The  perineum  may  show  marks  of  laceration  and  be  some- 
what lax  ;  the  fomchelte  being  absent. 

Tlu!  ni(/iiia  Is  eapaeioiis  and  lax,  the  walls  being  somewhat 
smooth.  The  remains  of  the  hymen  may  be  noticed  as  forming 
numerous  small  caruncles  (carunculie  myrtiformes). 

The  rervi.r  is  short  and  broad;  very  often  it  is  lacerated, 
generally  on  the  left  side. 

Diagnosis  of  Life  or  Death  of  Child. 

Jt  is  not  always  easy  to  decide  that  th(»  child  is  dead.  The 
woman  may  suspect  this  to  be  the  case  because  of  certain  vague 
sensations  of  coldness  about  the  ])ubes,  and  because  of  a  feeling 
of  weight  or  dragging.  She  may  cease  to  feel  the  movements 
of  the  f(Tetus. 

The  matter  can  only  be  settled  if  after  repeated  examination 
the  physician  fails  to  hear  the  ffotal  heart  or  feel  foetal  move- 
ments. If  at  the  same  time  the  uterus  ceases  to  grow,  and  the 
breasts  l)ecome  flabby,  it  may  be  inferred  that  the  child  lias 
perished. 

Hygiene  and  Management  of  Pregnancy. 

While  the  condition  of  the  pregnant  woman  is  a  purely 
physiological  one,  it  must  be  borne  in  mind  that  tlie  border- 
line between  health  and  disease  may  be  very  easily  passed. 
Hence  it  is  the  duty  of  the  physician  to  give  every  woman 
engaging  his  services  for  her  confinement  such  hygienic  instruc- 
tion as  she  may  require.     In  fact,  a  certain  degree  of  pro- 


T^V 


lIYdllCSI':  AND  MAyAdKMENT  OF  rUEaNASCY.      bh 

ro-ioiuil  Jit(on(ion  slutiiM  l)o  ^Ivon  to  all  women  throiij^hout 
I  lie   Nvliolc  jM'riod  of  j)r('i;ii;mcv. 

Diet:  'I'lic  diet  diiiiiiti'  ))r('}i;niiii<'V  sIiomM  Ik'  |)lain.  Simple, 
ci.-ilv  (li^tstil)le,  aiul  lii<;lily  milritioiis  food  slididd  he  tuken  at 
i(  <:iil:ir  intervals.  Overeating;,  espeeiaily  in  the  later  month^, 
shoidd  he  Li'iiarded  a<i;ainst.  Meat  should  he  oaten  hut  once 
dailv,  and  fruit,  hoth  cooked  and  IVe.sli,  siionld  form  a  |»riu- 
(•i)>ai   pari   of  all   meals. 

Exercise:  All  violent  exercise  should  he  avoi«led.  ^^'all^s 
ill  the  o|)en  air  and  simj)l(!  jrymnastics  within  doors  should  he 
indiilu'eil  in  daily.  All  liftin<iaud  strainintjj  should  he  avoided. 
IJicyclinti'  may  l)o  permitted  in  moderation,  hut  not  over  rough 
roa<Is.     'I'he  same  applies  also  to  carria<j::e-(lriviu<ji;. 

Clothing  should  he  worn  in  such  a  manner  as  to  avoid  undue 
pressure;  upon  either  chest  or  ahdomeu.  'i'he  corset,  if  worn 
at  all,  slioidd  he  a  short  one  and  should  he  very  loose.  Women 
with  lax  ahdoiuinal  walls  should  wear  an  ahdominal  support 
so  anaiiLi'ed  llial  the  pressui'e  is  exi^rted  upward. 

Bathing  siioiild  he  indulj^'ed  in  daily,  especially  since  the 
function  of  the  skin  is  increased  durin<j!;  prc(j:nan(;y.  If  the 
woman  is  in  the  hahit  of  taking  cold  haths  daily,  they  may  l)e 
continued,  hut  tlu;  initial  shock  may  he  avoided  hy  having-  the 
hath  warm  at  first,  and  then  adding  cold  water  to  it.  In  the 
later  months  at  least  two  warm  haths  ])er  week  should  he  taken. 
\'ery  hot  and  very  cold  h"''!is  should  he  avoided. 

The  care  of  the  lireasts  :  Attention  should  he  given  the  hreasts 
j)re[)aratory  to  nursing.  As  these  organs  enlarge,  the  clothing 
must  he  arranged  so  as  to  avoid  undue  pressure  upon  them. 
The  nij)i)les,  if  retracted,  should  he  drawn  out  and  gently 
manipulated  for  a  few  minutes  daily.  In  the  last  few  weeks 
daily  inunctions  of  the  nipples  with  fresh  cocoa-huttcr  or  while 
\aseline  may  he  recommended  as  a  prophylactic  against  fissures 
<Iuring  nursing.  The  use  of  astringent  lotions,  such  as  tea, 
hrandy,  etc.,  commonly  employed,  should  he  jiroscrihed. 

Should  vaginal  discharge  he  })resent,  daily  injections  of  horic- 
acid  solution  at  the  temperature  of  the  hody  may  he  employed, 
the  fountain-syringe  only  heing  used. 

Sexual  intercourse  must  he  restricted,  and  sliould  not  be 
indulged  in  at  the  menstrual  dates,  especially  hy  women  who 
have  previously  aborted. 


56  OliSTKTRIC  ANATOMY. 

Digestive  irregularities  .sli(»iil<l  he  cont rolled.  The  rrp;nlar 
action  of  the  howt;!  must  Im;  maintained.  Woman  seems  to  ho 
a  naturally  constipated  organism,  and  is  especially  rfo  duiino- 
pregnancy.  All  violent  purj^atives  should  he  avoided  ;  the  hest 
laxatives  are  aloin  and  cascara  sajjjrada.  The  mineral  waters 
|)r(tve  very  useful,  such  as  salines,  etc. 

The  urinary  excretion  re(|uire8  careful  attention  throughout 
|)i'eu;nancy.  Chemical  and  microscopical  examination  of  the 
urine  should  he  made  every  month  at  first;  and  in  the  later 
months  every  week.  The  total  amount  voided  in  tiie  twenty- 
four  hours  should  he  noted. 

The  nervous  condition  of  the  pregnant  woman  should  always 
he  noted.  All  undue  excitc^ment  should  be  avoided,  and  anv 
depression  of  spii'its  combated.  Plenty  of  sleep — at  least 
eight  hours  each  night — should  be  obtained.  Daily  naps  should 
be  encouraged.  > 

The  use  of  drugs  should  ho  avoided  as  much  as  possible  dur- 
ing pregnancy.  Large  doses  of  quinine  and  calonud  should 
not  be  administered.  The  all  too  common  habit  of  taking 
drugs  of  the  coal-tar  series  by  women,  to  relieve  headache,  etc., 
should  be  especially  discouraged  during  pregnancy,  on  account 
of  their  deleterious  action  on  the  heart.  Many  of  the  cases  of 
severe  cardiac  failure  following  labor  may  be  set  down  to  this 
pernicious  habit. 

The  physician  should  make  a  careful  general  examination  of 
every  })regnant  woman  under  his  care  about  the  eighth  month 
of  the  pregnancy.  A  careful  external  and,  if  thought  neces- 
sary, an  internal  examination  should  be  made.  The  pelvis 
should  be  measured  and  the  attitude  of  the  fo'tus  noted.  The 
breasts  and  nipples  should  also  be  examined.  Inquiry  shoidd 
also  be  made  as  regards  the  presence  or  absence  of  vaginal 
discharge.  If  present,  its  character  should  be  noted  and  a 
bacteriolog     ^  'examination  made. 

OBSTETRIC  ANATOMY. 

Foi  detailed  anatomy  of  the  female  pelvic  structures  the 
student  is  referred  to  special  works ;  or  to  obstetric  systems, 
such  as  Jewett's  "  Practice  of  Obstetrics." 

The  chief  anatomical  elements  concerned  in  labor  are  three 


«P»V; 


THE   UTKRVS. 


67 


ill  mitulMT,  namoly:  (1)  tlio  iit«'rns ;  (2)  llic  pclvi-^cnitul 
ciiiial  ;  (.'{)  tlio  Di'tiis. 

Ill  tln'  act  of  parturition  the  iimtiiiil  reaction  of  these  elo- 
iiiciits  is  coMcenied. 

Tlie  iifii-n.fi  may  l)e  coiicoivcil  of  as  a  iiiiiseiilar  sae  (i|)eiiiiin 
into  a  tMirv<'<l  tnl)e,  tiie  upper  part  of  wiiieli  is  l)ony,  tlierel'oro 
ijtriil  ;  and  tlie  \u\\vx  \yav{  yielding,  being  fornied  of  ninseld 
and  ()tlier  soft  structures.  This  en, -ml  (ithc  is  tlie  pelvi- 
nciiital  canal,  which  iiicludcH  the  disteiisibh;  vatjjiiia,  the  upper 
part  beii'.t^r  intrapelvic,  while  the  lower,  in  the  pelvic  lluor,  is 
siihpelvic. 

'nuifalnti  is  the  passenger,  and  coii>ists  of  two  ovoids,  the 
trunk  and  the  head  ;  the  forincr  plastic,  the  latter  more  or  less 
rigid,  and  therefore  the  more  important  as  regards  its  relations 
to  the  birth-canal. 

The  Uterus. 

At  .  .'rm  the  uterus  is  an  ovate  viscns;  it  is  less  part  of  the 
birtii-ianal  than  it  is  the  engine  by  which  the  [)assciigcr — the 
fu'liis — is  exj)elled. 

The  cavity  of  the  uterus  at  term  has  been  stated  as  measur- 
ing 12  inches  in  length,  9  inches  in  breadth,  and  8  inches  in 
depth. 

The  walls  of  the  uterus  vary  in  thickness  from  one-fourth 
to  one-fiftii  of  an  inch  ;  the  posterior  being  tliicker  than  the 
anterior. 

Tlic  muscle-fibres  of  the  uterus  mav  be  distinunished  at 
term  as  forming  roughly  three  layers:  an  outer,  a  middle,  and 
an  inner  layer : 

In  the  outer  layer  there  are  two  sets  of  fibres :  (1)  longitudi- 
nal and  (2)  transverse  (Fig.  21). 

The  /oiif/ifuduial Jibre.s,  posteriorly  from  the  junction  of  the; 
body  with  the  eerv'x,  pass  in  the  form  of  a  broad  band  verti- 
cally upward  over  the  fundus  and  down  the  middle  line  ante- 
riorly to  the  cervix ;  the  marginal  fibres  toward  the  fundus 
branching  off  to  interlace  with  those  of  the  round  and  broad 
ligaments. 

The  tramverse  fibres  arranged  at  right  angles  to  these  pass 
across  the  uterus  from  side  to  side ;  at  the  fundus  passing  from 
one  cornu  to  the  other.     These  fibres  interlace  in  great  part  at 


5,S 


OB.STm'RIC  ANA  TOMY. 


tlic  sides  of  tlic  iitoriis,  l>iit  some  of  tlieni  are  prolonged  along 
tlie  broad  and  the  round  ligaments  as  well  as  along  the  tubes. 


Via.  '1\. 


External  muscular  layer  of  the  posterior  wall  nf  Uio  uterus. 

In  the  middle  layer  the  tibres  have  no  delinite  direction  on 
account  of  the  numerous  bloodvessels  traversing  them.     They 

Fig.  22. 


Middle  muscular  layer  nt  the  fundus  :  a,  a,  superficial  layer  dissected  back  ; 
I),  branches  belonj^ing  to  the  inner  layer  ;  t,  t,  tubes. 

pass  in  every  direction — longitudinal,  transverse,  and  obli(jue — 
twisting  and  curving  about  t.ie  vessels.     Fre<juently  they  are 


THE   IJTERVS.  59 

arranged  in  the  form  of  a  fij^iire-of-cijrlit,  fonuinp^  riiiijjs  about 
the  vessels,  thus  const  it  utiii5j:  living  lijratures  (Fifz;.  2'2).  Tliis 
layer  is  probably  the  thickest,  and  is  most  marked  in  tlu;  upper 
segment  of  the  uterus. 

In  the  inner  layer  some  fibres  are  arranged  in  a  stsries  of  coii- 
ccutric  rings  about  the  orifices  of  the  tubes  (Fig.  2.')).  Other 
fibres  pass  directly  across  frotu 

one  cornu   to  the  other  trans-  ' ;^ 

ver>ely  ;  while  others  j)ass 
do\vinvii"d  longitudin;illy  to 
the  cervix,  in  the  middle  line 
of  the  anterior  and  posterior 
walls. 

Uterine     segments :      These 

layers  an;  not  all  distiiK-t,  but 

shade    imj)ei'ceptil)ly   into   one 

another.     In  the  hjuh'i'  part  of 

the  uterus  the  arrangement  in 

lavers    is    fairly  distinct;    but 

i»i  the  loicer  |)art  the  fibres  are 

moie  loosely  arranged,  passing     ^ 

chiefly  in   a  longitudinal  diree-  internal  surface  of  the  uterus  as 

i.:    ,,  shown    after  ineisiou    in  the    median 

•^^ '"•  line  of  the  anterior  wall.    (I'arvin.) 

Hence   tlie   uterus    may   be 
divided  into  two  portions,  the  upper  of  which  lias  a  frmer 
muscular  arrangement  than  the  lower. 

These  })ortions  are  termed  respectively  the  upper  and  th(i 
loirrr  ntcriiie  sec/vienf.s. 

The  line  of  separation  between  the  segments  lies  nearly  at 
the  level  of  the  uterovesical  fold  of  the  peritoneum,  and  is 
termed  the  irt)'((ctio)}-ri)i(/,  or  ndiid/'.^  i'i))f/. 

The  uj>per  segment  plays  an  active  rd/c  in  labor,  while  the 
lower  has  but  a  passive  rofc.  The  lower  segment  along  with 
the  cervix  must  undergo  dilatation  preparatory  to  the  exi)ulsion 
of  t.ie  fietus. 

The  upper  segment  includes  roughly  the  upper  two-thinls 
of  the  entire  body  of  the  uterus ;  while  the  lower  segment  and 
the  cervix,  which  are  nearly  of  ecpial  lengths,  form  the  remain- 
ing one-third. 

The  round  and  the  broad  ligaments,  which  have  become 


60  OBSTETRIC  ANATOMY. 

hyportrophiod  diiriiii;  j)r('u;niui('y,  s('rv(>  as  ^iiys  to  steady  tlie 
uterus  during  its  contract  ions,  so  that  its  long  axis  corresponds 
to  that  of  tlie  ])elvic  inlet. 

The  peritoneum  covering  the  uterus  is  finnly  attached  to  this 
organ  as  far  down  as  tlio  retraction-ring;  below  this  its  attach- 
ment is  loose  and  it  may  easily  he  stripjx'd  oil'.  Thus  the  site 
ol'  the  retraction-ring,  or  Bandl's  ring,  is  at  the  lower  border 
of  lirm  peritoneal  attaclunent. 

The  peritoneum  at  term  has  in  front  of  and  behind  the  uterus 
the  same  relations  as  iu  the  non-[)regnant  condition  ;  but  at  the 
.svV/c.s  it  lias  been  so  lifted  uj)  by  tiie  enlarged  uterus  that  it  does 
not  desc'end  into  the  ])elvis.  Tiie  broad  ligaments  have  become 
so  elevated  that  theii' bases  are  only  at  tlu!  pelvic  brim,  extend- 
ing on  either  side  from  the  ilio})ectineal  eminence  to  the  sacro- 
iliac joint.  Thus  there  exists  on  either  side  of  the  uterus  at 
term  a  large  triangidar  area  uncovered  by  j)erito)'eum.  Owing 
to  the  drawing  U[)  of  the  uterosacral  ligaments  the  pouch  of 
Douijhix  becomes  nuich  dee[)er  than  iu  the  non-pregnant  con- 
dition. 

The  Relation  of  the  Full- term  Uterus  to  Contiguous  Structures. 

The  intestines  do  jiot  descend  behind  the  uterus  at  all,  and 
iu  front  oidy  as  low  as  the  umbilicus.  A  j)ortion  of  the  rectum 
lies  behind  the  uterus,  ;ind  occasionally  a  looj)  of  the  sigmoid 
flexure  of  the  colon. 

The  urinary  bladder  lies  wholly  within  the  pelvis  before  the 
onset  of  labor,  its  highest  ])oint  being  below  the  symphysis 
pubis,  except  when  distended. 

The  cellular  tissue  about  the  uterus  exists  as  a  thin  layer 
behind;  but  in  front  there  is  a  broad  band  between  the  cervix 
and  the  bladder.  At  the  sides  of  the  uterus  it  is  enormously 
increased  as  compared  with  the  non-pregnant  condition.  At 
the  bases  of  the  broad  ligaments  (defined  above)  there  exists 
only  cellular  tissue  (no  peritoneum)  between  the  uterus  and 
the  })elvic  wall ;  this  de})osit  extends  u|nvard  and  backward 
between  the  layers  of  the  broad  ligament  into  the  iliac  fossa'. 

The  ureters  enter  the  ju'lvis  just  in  front  of  each  saero-iliac 
joint  and  pass  downward,  forward,  and  inward  to  the  neck  of 
the  bladder  in  such  a  way  that  they  are  not  in  the  least  liable 
to  pressure  between  the  uterus  and  the  bony  pelvis. 


1 


BONY  PELVIS. 


61 


The  shape  and  position  of  the  uterus  as  well  as  the  direction 
of  the  axis  of  its  cavity  chant;*'  as  tlie  organ  passes  from  its 
rchixed  state  to  one  of  active  contraction.  Tliese  will  tliere- 
fore  be  discussed  later. 


The  Pelvi-genital  Canal. 
Bony  Pelvis. 

Definition:    Tlie  pelvis  is  the  bony  basin,  or  canal,  which 
foiMiis  the  most  important  part  of  tiie  l)irth-canal  (Fig.  24). 

Fto.  24 


I'lie  ft'iiiale  pelvis.     (JewcUj 


Tile  leiMH  is  derived  from  the  liatin  p(/ri.'<,'A  bowl.  The  pelvic 
canal  is  irregularly  funnel-shaped,  flattened  from  before  back- 
ward, the  larger  end  looking  uj)wai'd  and  forward,  the  smaller 
downwai'd  and  backward,  when  the  woman  is  in  the  erect 
j)osition.  It  contains  in  the  non-pregnant  state  the  essen- 
tial organs  of  generation,  and  in  labor  the  child  is  expelled 
through  it. 


62  OBSTETRIC  ANATOMY. 

An  intimate  knowledge  of  the  pelvis  as  related  to  the 
mechanism  of  labor  is  essential  to  complete  understanding  of 
the  problems  of  the  art  of  obstetrics.        ' 

General  description :  The  pelvis  is  composed  of  the  sacrum, 
the  coccyx,  and  the  two  ossa  innominata.  Each  of  these 
bones  is  made  up  of  separate  parts  which  become  united  by 
the  twentieth  year  of  life.  The  articulations  of  the  pelvis, 
wliich  are  of  considerable  obstetrical  importance,  are  the  sacro- 
iliac joints,  the  sacrococcygeal  joint,  and  the  symphysis  pubis. 

The  sacro-iliac  joints :  The  opposed  surfaces  of  each  bone 
forming  these  joints  are  covered  with  thin  plates  of  cartilage. 
These  become  separated  by  spaces  containing  a  small  quantity 
of  glairy  fluid,  but  no  synovial  membrane  can  be  demonstrated. 
Each  of  these  joints  has  anterior  and  posterior  ligaments  and 
intercartilaginous  bands;  of  these,  the  posterior  are  by  far  the 
most  important.  Each  of  these  posterior  ligaments  is  formed 
of  three  fasciculi ;  the  two  superior  run  nearly  horizontally 
from  bone  to  bone;  wliile  the  inferior  passes  obliquely  down- 
ward and  inward  from  the  posterior  superior  spine  of  the  ilium 
to  the  third  and  fourth  sacral  vertebrae. 

The  sacrococcygeal  joint  has  an  interosseous  fibrocartilage 
which  permits  recession  of  the  coccyx.  Its  ligaments  are  of 
no  importance. 

The  symphysis  pubis :  The  slightly  convex  surface  of  each 
pubic  bone  is  covered  with  a  thin  plate  of  cartilage  sufficient 
only  to  fill  out  any  irregularities  in  the  bones  forming  the  joint. 
The  opposed  surfaces  are  held  together  by  an  intervening  mass 
of  fibrocartilage,  which  constitutes  the  interpubic  disk.  A 
small  cavity  is  frequently  present  in  the  centre  of  this  disk, 
the  result  of  absorption  of  the  fibrocartilage ;  it  is  non-syn- 
ovial  in  character. 

The  lujaments  of  this  joint  are  four  in  number — anterior, 
posterior,  superior,  and  inferior ;  of  these,  the  most  powerful  is 
the  inferior,  often  termed  the  ligamentum  arcuatum.  It  is  a 
strong  fibrous  bundle  passing  across  from  one  descending 
pubic  ramus  to  the  other,  blending  at  the  median  line  with  the 
interpubic  disk. 

Besides  the  ligaments  which  are  associated  with  the  pelvic 
joints,  we  have  the  sacrosciatic  ligaments,  which  play  a  very 
important  part  in  the  mechanism  of  labor. 


BONY  PELVIS.  63 

The  greater  sacrosciatic  ligament  arises  from  the  posterior 
inferior  spine  of  the  ilinni  and  irorii  tlie  side  of  the  sacrum 
and  coccyx.  It  narrows  and  thickens  in  its  middle  part,  be- 
comintr  broad  a^ain  at  its  anterior  attachment  to  the  inner  sur- 
face  of  the  ischial  tuberosity. 

The  lesser  sacrosciatic  ligament  takes  its  origin  from  the 
side  of  the  sacrum  and  coccyx,  and,  passing  in  front  of  the 
greater,  is  inserted  into  the  spine  of  the  ischium. 

Mobility  of  the  pelvic  joints :  Toward  the  end  of  gestation 
there  obtains  a  certain  degree  of  swelling  or  oedema  of  all  the 
interarticular  structures  of  the  pelvic  articulations,  which  per- 
mits of  some  slight  expansion  of  the  pelvis  during  labor,  under 
the  wedge-like  advance  of  the  fnetal  head.  The  sacrum  })er- 
nn'ts  of  a  slight  rotation  on  its  transverse  axis.  There  is  also 
a  hinge-like  motion  of  the  coccyx  on  the  sacrum  which  permits 
an  enlargement  of  the  anteroposterior  diameter  of  the  pelvic 
outlet. 

The  pelvis  presents  two  divisions,  the  false  and  the  true  pel- 
vis, the  dividing-line  being  at  the  plane  of  the  brim — /.  e.,  the 
plane  cutting  the  upper  end  of  the  sacrum,  the  top  of  the  sym- 
})hysis  pubis,  and  the  iliopectineal  line  on  either  side. 

The  false  pelvis  has  but  little  obstetric  interest ;  it  simply 
forms  with  the  vertebral  column  and  the  abdominal  walls  a 
funnel-shaped  approach  to  the  true  pelvis,  and  is  included  iu 
the  abdominal  cavity. 

The  true  pelvis  constitutes  that  portion  of  the  pelvis  lying 
below  the  iliopectineal  lines.  It  is  a  deep  basin-shaped  cavity,  the 
■posterior  wall,  formed  by  the  sacrum  and  coccyx,  being  shar})ly 
cm-ved  with  an  anterior  concavity.  The  anieriov  wall  is  formed 
by  the  sym})hysis  pubis  and  is  short  and  straight.  The  lateral 
walls,  which  are  formed  by  the  lower  portions  of  the  ilia,  the 
rami  and  tuberosities  of  the  ischia,  the  sacro-iliac  ligaments, 
and  parts  of  the  descending  'ami  of  the  pubes,  are  irregular  in 
outline,  sloping  inward,  so  that  the  transverse  diameter  of  the 
pelvis  is  less  at  their  lower  than  at  their  uj>per  extremities. 

The  true  pelvis  may  be  divided  into  three  portions:  1,  the 
inlet,  or  superior  strait;  2,  the  outlet,  or  inferior  strait;  3,  the 
extiavation,  or  cavity. 

(1)  The  inlet,  or  superior  strait,  of  the  pelvis,  sometimes  termed 
the  6rm,  is  usually  described  as  beiug  heart-shaped,  though  iu 


64 


OBSTETRIC  ANATOMY. 


the  fresli  state  it  is  more  nearly  circular.  Its  boundaries  are 
defined  by  the  toj>  of  tiie  sacrum  behind,  the  iliopectiucal  lines 
on  eitlier  side  and  the  top  of  the  symphysis  j)ubis  in  front. 

(2)  The  outlet,  or  inferior  strait  (Fig.  25),  is  bounded  by  the 
subpubic  ligament,  the  descending  rami  of  the  pubes,  the  rami, 
tuberosities,  and  spines  of  the  ischia,  the  sacrosciatic  ligaments, 
and  the  coccyx.  Its  outline  is  roughly  triangular  in  shape, 
i)ut  when  distended  by  tiie  advancing  head  in  labor,  it  becomes 
ovate,  owing  to  the  distensibility  of  the  sacrosciatic  ligaments 
and  the  yielding  character  of  the  coccyx  and  sacro-iliac  joints. 

Fio.  25. 


Outlet  of  pelvis.    (Leischman.) 


(3)  The  excavation,  or  cavity  of  the  pelvis,  is  bounded  by 
the  su})crior  and  inferior  straits,  and  comprises  all  that  portion 
of  the  j)elvis  between  them. 

J\jiitci'ior/i/,  the  cavity  is  bounded  by  the  sacrum  and  coccyx  ; 
antenorhi,  by  the  })ubic  l)ones  and  their  rami ;  iaieralh),  by  the 
lower  portions  of  the  ilia,  the  bodies,  tuberosities,  spines,  and 
rami  of  the  ischia,  and  by  the  sacrosciatic  ligaments. 

Tlie  jMfifcnor  wall  is  concave  from  above  downward  ;  its 
depth,  following  tho  sacral  curve,  is  11.5  to  12.5  cm.  (4|  to  5 
inches). 

The  anterior  wall  is  concave  from  side  to  side ;  its  depth  at 
the  symphysis  is  4  cm.  (1 1  inches). 

The  lateral  wall  is  about  9  cm.  (3^  inches)  in  depth. 


BONY  PELVIS. 


66 


For  description  each  must  be  divided  into  three  portions, 
wlii<'h  may  he  mapped  ont  in  Fi«;.  2(1. 

'I'he  A'/'^/  jKH'tuni  is  triangular  in  sliape,  its  hase  heini:;  a  Une 
(h-awn  from  tiie  iliopectineal  eminence  (o  the  top  of  the  sacro- 
iliac joint,  its  lateral  boundaries  meeting,  at  the  iliac  spines. 
This  portion  is  bony  thrcMighout,  and  is  smooth  and  ciu'ved. 

The  second  ixtH'um  lies  forward  and  somewhat  below  the 
first,  and  has  but  little  bone  in  its  comjjosition,  being  ciiietly 
made  up  of  the  membranous  tissues  of  the  foramen  ovale  cov- 
ered bv  the  obturator  muscle. 

These  structures  are  at  term  somewhat  softened  and  more 
elastic  than   in  the  uon-pregnaat  condition.      When  the  pre- 

Fio.  20. 


Side  view  of  pelvis. 


seating  part  in  labor,  in  advancing,  impinges  on  these  structures 
their  recession  converts  this  j)()rtion  of  the  lateral  wall  into 
more  or  less  of  a  groove,  with  bony  edges  and  elastic  floor ; 
this  groove  d(?epeus  as  it  descends,  and  its  direction  tends  towar<l 
the  lower  border  of  tlie  symphysis.  The  ischiopubic  ramus 
forming  the  lower  part  of  this  portion,  is  (curved  laterally  out- 
ward an<l  lends  itself  to  the  contimiation  of  this  groove. 

The  third  portion  is  ma<le  up  mainly  of  the  pyriformis 
muscle  and  tiie  elastic  sacrosciatic  ligaments ;  its  borders  are 
bony,  being  composed  posteriorly  (»f  the  lateral  borders  of  the 

.^— Ob?t. 


66 


OBSTETRIC  A }^ ATOMY. 


sucniiii  .'ind  coccyx,  and  anteriorly  l)y  llic  poHlcrioi-  cd^c  of  tlic 
ilium.  Uurin^  descent  oi' tiie  liead  those  liganienls  and  iniiscjes 
are  |)ut  on  the  stretoii,  and  this  portion  is  tlius  converted  into 
a  lonji,  spiral  groove,  wliich  deepens  as  it  descends  and  turns 
forward. 

The  second  and  tliiid  portions  of  tlie  lateral  walls  are  termed 
respectively  the  anterior  and  the  posterior  lateral  (/rooce.s  of  the 
pelvis. 

The  question  of  the  role  they  play,  if  any,  in  the  mechanism 
of  labor  will  be  discussed  later. 

Obstetric  planes  of  the  pelvis  :  The  [)elvic  canal  varies  in  si/(! 
and  shape  at  different  parts  of  its  course;  these  variations  are 


Fig.  27. 


Obstetric  diameters  of  the  pelvic  brim:   A  A',  conjugate  diiimetcr;  T  T',  transverse 
diameter  ;  L  O,  left  oblique  diameter ;  R  O,  right  oblique  diameter.    (Jewett.) 

best  understood  by  means  of  a  series  of  transverse  planes 
through  the  pelvic  cavity  at  different  levels.  Three  of  these 
are  of  special  importance  obstetrically  :  the  plane  of  the  brim, 
the  plane  of  the  outlet,  and  middle  plane  of  the  cavity. 

Plane  of  the  brim :  The  anatomical  brim  of  the  pelvis  is  at 
the  level  of  the  true  pelvis,  while  the  obdetricfd  plane  of  the 
brim  is  situated  at  the  level  of  least  expansion  of  the  uj)per 


BONY  PELVIS. 


67 


part  of  tlu'  pclvic!  canal.  Tliis  lies  at  tlic  lovcl  of  tlic  Miimuit 
of  tlie  sacral  promontory,  tlic  ilioju'ctincal  line,  and  llic  posfrrior 
siirj'acc  iA'  the  synipliysis  pnl»is,  at  a  point  1  cm.  (!f  oi' an  incii) 
brioir  its  upper  margin  (Fi<i'.  27). 

Plane  of  the  outlet:  At  the  outlet  al.-o  the  anatomical  and 
ol)stetrical  planes  differ.  The  obstetrical  plane  ol'  tlu'  outlet 
is  defined  hv  the  tip  of  tiie  sacrum,  the  lower  border  of  the 
ischial  spines,  and  the  lower  border  of  the  symp]iysi>  pubis  at 
a  point  just  above  the  lower  margin  (l''ijj,-.  2S). 

Via.  28. 


Ohstftric  (liiinit'tiTS  of  the  pelvic  oiitU't :  S.  P.,  snoroimhic  (liaiiutcr;  Hi.  I.,  liis- 
ii^chiiil  diameter;  IJi.  S.,  bisischiatic  diamctiT.    (.k-wttt.) 

Plane  of  the  cavity:  The  middle  plane  of  tlie  pelvic  cavity 
lies  at  the  level  of  the  up])er  end  of  the  thii-d  ])iece  of  the 
sacrum,  the  middle  of  the  symphysis  ])ubis,  and  tlie  centre  of 
the  acetabular  (javitics  (Fi^.  25)). 

Internal  pelvic  diameters :  The  dimensions  of  (ricJi  plane  are 
measured  in  four  directions  :  the  aiiter()])()stcrior,  the  transverse, 
and  the  two  oblique. 

At  the  plane  of  the  brim :  The  auicropoderior  dUiineler  of 
the  brim  is  the  least  distance  between  the  sacral  promontory 
and  the  symphysis  pubis.      It  is  measured  from  the  middle  of 


68 


OBSTETRIC  ANATOMY, 


the  sacral  promontory  to  the  jjosturior  surfaco  of  tlic  symphy- 
sis, at  a  point  1  cm.  (f  inch)  below  its  upper  margin.     It  is 


Diagram  showing  axes  and  planes  of  pelvis  :  A  B  C  D,  axis  of  entire  parturient 
canal;  X,  anus  as  distended  at  acme  of  expulsion;  E F,  plane  of  brim  ;  K L,  mid- 


plane  of  cavity ;  M  N,  plane  of  outlet ;   O  P,  axis  of  brim ;   Q  R,  axis  of  mid-plane  ; 
S  T,  axis  of  outlet ;  //  H.  horizon  ;  E  N,  diagonal  conjugate  diameter. 

termed  the  conjugate,  or  true  conjugate,  and  measures  11  em. 
(4f  inches)  (Fig.  27). 


I 


BOXY  PELVIS. 


<>U 


rianes  of  the  pelvis  with  horizon  :  A  B,  horizon ;  C  D,  vertical  line  :  A  B  1,  niigle 
of  iiicliiiiition  of  jielvis  to  horizon,  e<iual  todoJ ;  B  I  (',  an^'le  of  inclination  of  jh'IvIs 
to  s|»inal  column,  ccitiai  to  L')(P;  (;  I  .1,  angle  of  inclMiation  of  s.icruni  to  spinal  col- 
umn, e(nml  to  i:iO°;  K  K,  axis  of  pelvic'  inlet;  L  M,  mid-plane  in  the  middle  line; 
N,  lowest  point  of  mid-plane  of  ischium.    (I'layfair.) 


The  inlet,  or  superior  strait. 

A  P,  anteroposterior  diameter,  4..S  to  4.5  inches,  or  11-llV^  centimetres. 

TS,  transverse,  r,:^  "       ,or       13U 

R  O,  right  nbli(|ue,  4.7  to  4.!>      "         or  12-12W 

/>  0,  left  obli(Hie,  4.7  to  4.9      "         OT  \2-V2% 

The  circumference  of  the  inlet  is  l'),b  inches,  or  40  centimetres. 


70  OUSTKTIHC  A  ^A  TOM  Y. 

Tlio  fr<in.srci'.s('  (li<t>ii(ffi' {F\^.  ^\)  is  tlio  jrroatcst  distance 
Ix'twooii  the  iliojH'ctiiical  lines,  and  measnros  13.5  cm.  (5| 
inclK's). 

Tlie  o/>//Vy//fw//V/;/*f^'/'.s' (Fi^.  .■)! )  are  ineasnred  one  fVotn  the 
riji'lit  and  the  other  tVoni  tlie  left  .-aero-iliae  joint  wliere  it  inter- 
sects  tile  iliojM'etineai  line,  to  tlie  opposite  iliopeetineal  emi- 
nence. Tlie  ri«;ht  oi)li([nc  sprinjjjs  from  tlie  I'iiiht,  and  the  left 
ol)Ii(pie  from  the  left,  sacro-iiiac  joint.  Thay  each  mcasni'e 
Mi)ont  12.-")  <'nK  (5  inches). 

At  the  plane  of  the  cavity:  The  notlcrojiosftrior  <li(i7n(f('r  is 
the  distance  iVoni  the  npper  niaruin  of  the  third  piece  of  the 
sacrnm  to  a  point  midway  on  the  j)<)stcrior  snrfaco  of  the  sym- 
physis (Fig.  30),  and  is  12.5  cm.  (5  inclies). 

The  fr<tn.srrrKc  (li(int<'f<'r  is  the  greatest  diameter  of  tlie  pelvis 
at  this  plane,  and  measnres  12  cm.  (4|  inches). 

I'he  ohliijuc  (Vimndcrx  of  this  plane  are  valneless  from  an 
obstetrical  point  of  view. 

At  the  plane  of  the  outlet :  The  (iiif(ropoi<terior  dUtmctcr  is  a 
line  drawn  from  the  tip  of  the  sacrum  to  a  point  just  above  the 
lower  l)or(](;r  of  the  sympliysis  pubis  (Figs.  28  and  29).  Jt 
measnres  11.5  cm.  (4.^  inches). 

The  tr<utxr<ri<c  ilidiiicfi  r  at  this  })lanc  may  be  measured  in 
two  ])laces  (Fig.  2<S).  The  greatest  transverse  diameter  is  tlie 
bisischial  line,  which  is  measured  from  a  point  on  the  inner 
surface  of  one  ischial  tidxM'osity  at  the  mid(]le  of  its  ])osterior 
bordei',  to  tlie  same  point  on  the  opposite  side.  This  measures 
11.5  cm.  (4^  inches). 

Tlie  least  transverse  diameter  is  the  distance  between  the 
ischial  spines,  the  bisischiatic  diameter,  which  measures  10.5 
cm,  (4 J-  inches). 

The  ohlUjUc  (Vtdincfci'H  at  this  jilane  are  of  no  importance. 

Ft  will  be  noted  by  com})aring  the  dimensions  at  tlie  ditfer- 
ent  planes,  that  the  transverse;  diameter  of  the  pelvic  canal 
grows  progressively  smaller  from  the  brim  to  the  outlet ;  the 
difference  between  these  being  2.5  cm.  (1  inch);  and  also 
that  the  anteroj)osteri()r  diameter  of  the  pelvic  canal  is  0.5 
longer  at  the  outlet  than  at  the  brim. 

Measurements :  The  hitcnxil  (JiamcterK  of  the  bony  pelvis 
as  stated  in  the  following  table  are  sufficiently  accurate  for  all 
practical  j)urposes,  and  should  be  memorized : 


Tiri':  SOFT  r.inrs  of  tiif  fflmc  caxal 


71 


AiitcrnjioHtiTlnr. 
Ilriiii,       10     cm.  (4  iiiclu's). 

(\mt<,,   II..") "  m   "  ) 

Oulirt,      12.5   "     (5        "     ) 


(>lili(|iu;. 
11.5  oni.  (4.\  inches"!. 
11.5   "     (1.1       "     ) 
11.5    "     (A]       "     ) 


TriinHVurHc. 
12.5  cm.  (5  inclieH). 
11.5   "    (li      "     ) 

ino   "    (-1         "     ) 


Inclination  of  the  pelvis:  Tlio  inclination  (!'^i^.  .*)())  of  t lie 
plaiicof  the  jx'lvic  brim  lo  the  liori/.on,  with  tiu;  \V(»nian  in  the 
erect  po-ition,  may  hcstati'd  ais  tit'ty-tivc  (Icjrrcos.  Tiio  inclina- 
tion of  the  jK'lvis,  of  conrso,  (lilfcrs  witli  changes  of  postnrc. 
In  the  erect  position  tho  ,syni[)liysis  pubis  is  nearly  !)  cm.  {l>\ 
inches)  below  the  level  of  the  promontory  ;  and  the  coccy.x  is 
2  cm.  {'I  inch)  above  the  level  of  the  lower  border  of  the 
.•^vmj)hvsis  pnbis,  the  pnbococcygeal  line  making  an  angle  of 
ten  degrees  with  the  horizon. 


The  Soft  Parts  of  the  Pelvic  Canal. 

The  lower  sognu.nt  of  the  nterns  and  the  cervix  form  a  part 
of  the  birth-canal ;  while  the  nj)per  segment  is  the  chief  sonrce 
of  the  j)roj)elling  jxjwer.  This  portion  of  the  soft  parts  has 
already  been  deserib(!d. 

Th(!  soft  partH  irliirh  luw-  tlie  houi/  ^x'/rifi  and  thos(>  which 
contribute;  to  the  formation  of  the  pe/ricjfoor  ai'e  of  great  ob- 
.stetric  importance.  Tlie  former  diminish  somewhat  the  diame- 
ters of  the  bony  cavity ;  the  latter  form  the  lower  portion  of 
the  birth-canal. 

The  psoas  and  iliacus  muscles,  which  lie  at  the  brim,  dimin- 
ish the  transverse  diameter  o^'  this  ])oi'ti()n  of  the  ])elvis  a 
quarter  of  an  inch  on  either  side,  thus  bringing  this  diameter 
down  to  about  the  size  of  the  oblique  diameter. 

The  external  iliac  vessels  run  along  the  inner  borders  of 
these  muscles,  and  the  main  trunk  of  the  lumbar  plexus  fol- 
lows the  course  of  the  psoas,  the  crural  nerve  running  between 
the  psoas  and  iliaeus  muscles. 

The  obturator  internus,  which  is  but  a  thin  muscle-sheet, 
covers  ])ortion.s  of  the  anterior  and  lateral  walls  and  a  j)art  of 
tiie  small  .sciatic  notch.  Thus  it  practically  covers  the  anterior 
inclined  groove  of  the  pelvis,  and  is  by  many  thought  to  make 
the  groove  of  but  little  value  obstetrical ly. 

The  pyriformis,  which  is  a  thin  fan-shaped  nuisele,  lies  a 
little  over  the  edge,  of  the  .sacrum  and  conipletely  fills  the  great 


72  OBSTETRIC  ANATOMY. 

scijitio  notcli,  thus  r()iitril)uting  to  the  formation  of  the  floor 
of  the  so-called  posterior  j)elvie  groove. 

Tile  anterior  wall  of  the  jx^lvis  is  not  eovere<l  by  nuisele, 
but  (luring  pregnancy  the  bladder  lies  in  relation  with  it. 
During  labor  the  greater  })art  of  this  viscns  is  drawn  up  above 
the  inlet ;  but  its  l)ase  may,  in  tedious  labors,  be  subjected  to 
])rolonged  pressure  between  the  head  and  the  })ul)es,  thus 
damaging  it  to  such  an  extent  that  sloughing  may  occur  and 
vesicovaginal  fistula  result. 

The  rectum  lies  in  front  of  the  left  sacro-iliac  joint.  It  runs 
forward  and  inward,  descending  in  the  median  line  down  the 
anterior  surface  of  the  sacrum  and  coccyx.  When  distended 
it  may  encroach  on  the  })elvic  s[)acc  to  a  very  considerable 
extent.  Its  preseiice  in  this  portion  of  the  pelvis  is  supposed 
to  account  for  the  greater  fre(|ueney  with  which  the  long 
diameter  of  the  fetal  head  occupies  the  right  oblique  diameter 
at  the  onset  of  labor. 

The  pelvic  floor  com]>rises  tlic  soft  structurL?  which  close  the 
outlet  of  the  bony  pelvis.  Its  function  is  to  support  the 
pelvic  viscera.  Its  upper  limit  is  the  peritoneum,  its  lower, 
the  skin  ;  it  is  ])crforjited  by  the  rectum,  vagina,  and  urethra. 

Hart  has  divided  the  pelvic  floor  into  two  segments,  as 
follows:  the  j)osterior  vaginal  Mall  and  the  soft  structures 
behind  it  constitute  the  mcvdl  segment ;  the  anterior  vaginal 
wall  and  the  soft  structures  in  front  of  it  compose  the  pubia 
segment. 

In  labor  the  ]>nbic  segment  is  drawn  uj)ward  and  the  sacral 
segment  is  pushed  downward  and  distended  as  the  foetus 
descends.  The  resiliency  of  the  sacral  segment  holds  the  fa?tal 
mass  in  close  relation  with  the  ischiopubic  ran. i  during  the 
latter  part  of  labor,  and  assists  in  its  final  expulsi  )n. 

The  pelvic  floor  when  stretched  by  the  fietus  measures, 
from  the  tip  of  the  sacrum  to  the  anterior  border  of  the 
])ubic  segment,  about  5  inches  (12.75  cm.).  It  is  mainly  com- 
posed of  nniscles  and  fascia-. 

The  muscles  forming  the  pelvic  floor  are  the  levator  ani,  the 
sj)hincter  ani,  the  transverse  muscles  of  the  perineum,  and  the 
sj)hineter  vagimic. 

The  levator  ani  nniscle,  which  is  the  most  im|)()rtant,  takes 
its  origin  from  the  posterior  layer  of  the  triangular  ligament, 


TIIK  SOFT  PARTS  OF  xlIK  I'FLVIC  CANAL.  7;> 

from  tlie  spine  of  tlu?  iscliimn,  and  from  tlio  wliole  kinp:th  of 
tlio  "wliltc  lino'"'  (Fi^r.  ^>,2).^ 

Those  fibres  wliieh  arise  from  the  puhes  pass  baeUward  to 
\)v  inserted  into  the  last  two  {)ieees  of   tiie  coccyx,  and  on 


Fig.  32. 


Drnwinji  from  ii  iihot(inra])li  of  a  dissectioti  iiukIc  nt  tli<'  I-oiifr  l^liiiid  College 
Ilnspital  :  1,  symiihysis :  J,  coccyx:  :'.,  anus;  1,  suiici  licial  (itiri's  fiuin  tlu'  )aihic; 
oriuiii  of  the  levator  aiii  :  .">,  deeiier  titiics  from  the  iniliic  oriKin  ;  'i.  Iil>res  from  the 
"  white  line";  7,  tibres  from  ilu'  .spine  of  the  iseiiium  ;  ,s,  gluteus  maxinuis  muscle, 
(iirownin^'.) 

tlu'ir  way  send  fibres  to  tlic  urethra,  vajj^ina,  and  the  internal 
sj)hineter  ani,  and  a   f  •   to  unite  with  those  of  the  opposite 


74 


OBSTETRIC  A  NA  TOMl. 


side  behind  tiie  anus.  Tiiat  jmrt  arising  from  the  "  white 
line  "  and  the  rest  of  the  line  of  origiii  whieh  forms  the  greater 
bulk  of  the  musele,  runs  backward,  downward,  and  inward 
to  the  side  of  the  cocevx  and  lower  end  of  the  sacrum.  I'he 
muscle  thus  forms  a  diaphragm  with  the  concavity  uj)ward. 


Fio.  33. 


(Coronal  siM'tion  of  tlio  jK-lvis:  .1,  ilium;  7',  iscliiiiui :  r,  n(H't!il)\ilinii ;  D,  ]ts(ms 
miiKniis  uiiisch^  ;  K,  ()))turntor  interims  :  F,  loviitor  ani :  (i,  .sphincter  ani  oxtcrnus  ; 
a,  transvcrsiilis  fascia  :  /),  iliac  fascia  ;  c,  obturator  fascia  ;  (/,  "  white  line"  ;  e,  recto- 
vesical fascia  ;  /,  Aleoek's  canal.    (Browning.) 

The  other  muscles  entering  into  the  formation  of  the  pelvic 
floor  form  a  second  layer  thinner  than  that  formed  by  the 
levator  ani.  They  all  meet  at  the  (Central  ])oint  of  the  ])eri- 
neum. 

The  fascia   forming  the  pelvic  floor  is  j)rol)ably  a   more 


THE  SOFT  PARTS  OF  THE  PEE  VIC  CANAL. 


75 


iiiij)orlant  clement  ol)stetrically  tliaii  tlic-  muscle  layer.  It 
iiia\'  l)c  (lcscril)e(l  in  two  })()rtions,  a  parietal  and  a  visceral 
layer  (Fi^.  -i-i). 

The  parietal  layer,  wliieli  is  the  less  imj)()rtant,  covers  the 
iiiiiscles,  paddiiiji:  tiie  sides  of  the  j)clvis  ;  in  front  it  forms  the 
j)(»sterior  layer  of  the;  trianj>;ular  liii:;ament,  and  is  perforated  hy 
the  urethra  and  vagina;  at  the  hack  it  helps  to  cover  the 
sciatic  notches. 

The  visceral  layer  is  continuous  with  the  fascia  covering  the 
sides  of  the  pelvis.  J''rom  its  line  of  origin  at  the  "white  line" 
the  visceral  layer  passes  downward  and  inwai'd  to  the  middle 
line,  where  its  lihrcs  fuse  with  the  connective  tissue  at  the  hase 
of  the  bladder,  the  vagina,  and  the  rectum,  thus  slinging  thes(! 
striictinvs  in  the  pelvis.  On  its  lower  surface  is  the  levator 
ani  muscle. 

The  perineum  may  be  defined  as  that  portion  of  the  body 
lying  between  the  anus  and  the  orifice  of  the  vagina.  Jt  is 
formed  by  the  perineal  bod ij  (Fig.  '34),  which  is  the  aggrega- 

Fi(i.  34. 


TIh' cxtci'iml  KC'iiitals,  us  seen  in  uicsjnl  section;  k.  iiiius;  /),  pcriiifiil  body;  c, 
v,i','iu!i  :  (/,  urctlira:  r,  Inliiinii  minus;/,  clitoris;  ,7,  fossil  niivicularis,  in  front  of 
wliicli   is  tiic  liynicn.     (Ucnle.) 

tion  of  the  tissues  lying  between  the  rectum  and  vagina  below 
their  point  of  contact.  On  sectioji  the  perineal  body  is  tri- 
angidar  in  outline  and  pyramidal  in  form.  Its  skin  surface 
(base)  from  the  anterior  ))art  of  the  amis  to  the  i)osterior  part 
of  the  vaginal  orifice  measures  about  2.0  cm.  (1  inch). 


76 


OBSTETRIC  ANATOMY. 


The  parturient  axis :  Tlio  niatlicniatioal  axis  of  the  pel- 
vic canal  is  a  line  Avliich  pierces  eadi  pelvic  ])lane  per- 
pendicularly at  its  central 
point.  This  axis  is  a  curved 
line  with  its  concavity  for- 
ward,  and  re})resents  very 
closely  the  course  the  fo'tal 
head  follows  in  its  descent 
through  the  pelvis  in  normal 
labor  (Fig.  ;i5). 

The  axis  of  the  brim  if  pro- 
longed would  strike  the  tip 
of  the  coccyx  below,  above 
it  would  touch  a  j)oint  on 
the  abdomen  near  the  umbil- 
icus. 

The  axis  of  the  bony  outlet, 
if  prolonged  upward,  would 
pass  innnediately  in  front  of 
the  sacral  promontory.  The 
axu  of  the  plane  of  the  ndvo- 
vdc/iiKil  rhicf  at  the  moment 
when  the  head  is  exj)elled,  is 
a  line  directed  upward  almost 
parallel  with  the  lower  part 
of  the  abdominal  wall  of  the 
mother  (Fig.  29). 

Hirst  points  out  that  the 
direction  of  the  pelvic  canal 
depends  entirely  on  the  curve 
of  the  sacrum,  and  that  this 


Axis  of  the  birUi-onnal :  r,  anus;  ah, 
plnnc  of  outlet  of  conipleted  canal;  r, 
))erpen(licular  to  plane  or  axis  of  ex- 
pulsion. 


differs  in  every  pelvis. 


The  Foetus. 

The  third  anatomical  element  concerned  in  labor  is  the  body 
to  be  expelled.  This  consists  of  the  whole  ovum,  viz.,  pla- 
centa, membranes,  and  foetus.  The  anatomy  of  the  ])lacenta 
and  membranes  has  already  l)een  described,  therefore  this 
section  will  be  concerned  with  the  footus  only. 


THE  FCETUS. 


77 


The  mature  foetus:  At  term  the  fn'tiis  virdsiircs  usually 
iH'tux'ou  40  and  ol  cni.  (l(S-20  iuchos)  iu  Icu^^tli.  Its  irci(//il 
jivorages  from  3150  to  o21)0  grainmos  (7-7|  j)ouu(ls),  uialos 
beint'"  soiuewliat  licavier  than  females.  Not  rarely  ti>e  weight 
may  reach  as  high  as  5400  grammes  (12  j)()un(ls),  the  phe- 
nomenal weight  of  9000  grammes  (20  pounds)  has  been 
recorded. 

The  hf'dd  bears  a  much  larger  proportion  to  the  trunk  than 
in  the  adult.  Its  diameters  are  greater  than  those  of  any  part 
of  the  trunk,  and  are  more  incompressible.  It  therefore  offers 
the  principal  resistance  to  the  passage  of  the  child  through 
the  pelvis.  In  the  mechanism  of  labor  it  is  with  the  head 
that  obstetric  problems  are  mainly  concerned. 

The  icho/e  bodij  of  the  fcetus  before  and  during  labor  forms 
a  roughly  ovoid  mass.  So  long  as  the  long  diameter  of  the 
f(etal  ovoid  coincides  as  nearly  as  possible  with  the  axis  of 
the  parturient  canal  the  mechanism  is  a  normal  one.  This  is 
the  case  whichever  extremity,  head  or  breech,  the  fa'tus 
presents. 

The  head  :  Obstetrically,  the  f<etal  head  presents  two  divi- 
sions:  (1)  the  ci'dnlal  vdult ;  (2)  the  (-rd}iidl  bdne  diul  fdce. 

The  vault,  which  is  com})ressiblo,  is  composed  of  thin,  inem- 
brano-cartilaginous  plates,  which  are  in  themselves  flexible 
and  are,  with  the  exception  of  the  frontal  bone,  united  to  the 
base  and  to  each  other  by  membrane  only. 

The  base  is  formed  of  bones  which  are  solid  and  firmly 
ankylosed.  It  is  therefore  incompressible,  thus  aflbrding 
protection  during  birth  to  the  ganglia  at  the  base  of  the 
Imiin. 

The  attachment  between  the  base  and  the  vault  of  the 
cranium  is  along  a  line  drawn  through  the  junction  of  the 
orbital  and  "squamous"  parts  of  the  frontal  bone,  continued 
ba(!kward  by  the  squamous  suture  and  downward  by  the 
hinge-like  junction  of  the  tabular  part  of  the  occipital  bone 
to  the  basilar  and  condylar  portion. 

The  bones  forming  the  cranial  vault  are  the  two  parietal, 
the  frontal,  and  the  "s(|uamous"  portions  of  the  occipital 
and  of  the  two  tomj)orai  bones.  These  are  united  only  by 
the  unossiHed  external  ])eriosteuni  and  by  tlu;  dura  mater. 
The  plasticity  of  the  vault  is  due  to  the  cartilaginous  char- 


78 


OBSTETRia  ANATOMY. 


actcr  of  the  l)()nc'.s  and  to  tlio  existence  of  the  niemhranous 
interspaces. 

The  sutures  of  the  vault  are  the  niemhranous  intervals 
betwecni  two  adjacent  hones.  The  most  important  are  the 
smjiHnl,  running  between  tlie  two  parietals ;  tlie  fronUil, 
between  the  two  j)ortions  of  the  frontal  bone  ;  the  coroiid/, 
between  the  frontal  and  j)arietals  ;  and  the  /(iinhdoicht/,  between 
the  parietals  and  the  occipital  bone  (Figs.  iiG  and  37). 


Fi(i.  36. 


Fio.  37. 


Anterior  and  posterior  fontanellcs,  saftittal,  lambdoidal,  coronal,  and  frontal 

sutures. 

The  fontanelles  are  the  larger  spaces  formed  by  the  widen- 
ing out  of  the  sutures  between  the  angles  of  three  or  four 
adjacent  bones. 

The  largest  is  the  anlerior  fontancllc,  or  brerpiKt,  situated  at 
the  junctio!)  of  the  sagittal,  the  coronal,  and  the  frontal  sut 
ures.  It  is  kite-shaped,  or  (juadrangular,  with  its  most  acute 
angle  forward.  Its  average  diameter  is  about  one  inch,  but 
its  size  varies  in  different  heads.  Four  lines  of  sutures  run 
into  it. 

The  posterior,  or  f<))U(/I,  fotiidiwllc  is  formed  at  the  junction 
of  the  sagittal  and  lambdoidal  sutures,  and  is  merely  felt  as  a 
small  triangular  depression.  'J'here  are  three  lines  of  sutures 
running  into  it. 

TcinpordI  fontanellc.'^ :  At  the  junction  of  the  temporal  with 


ill 


THE  FCETUS. 


l''i(i.  ;{>:. 


'J'lie  (liniiK'tors  of  tlie  fiutiil  heiiil:  O  V,  Mcci|iitofii)iital  ;  O  B,  i-ulxicciiiito- 
hrcjrniiitif: ;  B  'J',  c'c'rvicobreKiiuitio.  The  iiiaxiinuiii  diiiiiR'tcr,  (icci|iitomciital,  is 
imiicati'il  by  the  luiifj  dotted  urrow,  Meusureineiits  arc  euiitiuictrcs.  (Furubeuf 
iiml  Vurnit;r.) 

Fi(i.  30. 


^^^-"^ 

• 

^^^V^ 

y/^ 

* 

>v^ 

/ 

- 

^ 

/ 

1    2?                                                                                                                                ^ 

i//^-^ 

\                     ^ 

^ 

\^ 

y 

KiiWKiiij,'  (linmotiTS  of  the  flexed  liead  :    /'  /',  Hii)arietal  diameter,  '.M  ,  cm.     (After 

Faralieuf  and  N'ariiiur.j 


80 


ORSTETRKJ  ANA  TO  MY. 


the  piirictal  and  occipital   hones,  on  cither  side  of  the  head, 
tiiere  exists  a  small  (jiiadrilateral  t'oiitanclle. 

Fd/.se  f()>itaii('//r.s  are  occasionally  ohserved  either  in  the 
hody  of  tlie  hone  or  in  the  conrse  of  a  sutnre.  These  are 
due  to  some  defect  in  ossilication.     A  (|[uadrilateral  false  fon- 


FiG.  40. 


Vertex.    Left  occipitu-aiitcrior  position.     (Ribemont-Dessaigncs  and  Lepage.) 


,7 


tanelle  is  not  infrequently  to  he  felt  in  the  line  of  the  sagit- 
tal puture  a  .short  distance  from  the  usual  small  fontanelle. 

Obstetric  landmarks:  Certain  landmarks  ahout  the  Ja'ta/ 
head  are  of  considerable  obstetrical  imj)ortance. 

The  vericx  is  that  portion  of  the  head  between  the  anterioi- 


THE  F(ETUS. 


81 


and  posterior  fontanelles,  and  extending  laterally  to  the  parie- 
tal eminences. 

The  orclpal  is  that  portion  of  the  iiead  behind  the  posterior 
f'ontanelle. 

'riu'  slitcipiU  is  that  portion  of  the  head   in  front  of  the 
bregma. 

Fig,  41. 


Vertex.    Right  occipito-antcrior  position.    (Ribemont-Dessaignes  and  Lepage.) 

The  (jlahcUa  is  the  spaeo  over  the   root  of  the  nose  and 
between  the  supra-orbital  ridges. 

Five  jirotuberant'e.H  are  j)resented  by  the  cranial  bones  : 
The  occipitdl  profuhcnincc  situated   in  the  middle  of  the 
squamous  ]K)rtion  of  the  occipital  bone  about  2.5  cm.  (1  inch) 
behind  the  ]K).sterior  fontanelle.       The  jxirktal  protubenmce 
is  the  boss  or  eminence  in  the  centre  of  each  parietal  bone. 
6— Obst. 


82 


OBSTETRIC  A  NA  TOMY, 


The  fronUil  jjrotubercmce  is  tlie  eniiiieiice  in  the  centre  of 
each  frontal  l)onc. 

Diameters  of  the  foetal  head  :  OcclpUofrontdl,  extending 
from  tlie  ghihclla  to  the  tip  of  tlie  occij)ital  protuberance ; 
1 1.5  cm.  (4^  inches) ;  posterior  end,  Fig.  38,  too  high. 


Fig.  42. 


Vertex.    Right  occipito-posterior  positijii.    (Ribemoiit-Dessaignes  and  Lepage.) 

Occipitomental,  extending  from  the  tip  of  the  occipital  pro- 
tuberance to  the  centre  of  the  chin.  Mea.sures  14  cm.  (5tV 
inches).     The  posterior  end,  Fig.  38,  is  too  high. 

SuhoccipitohregmaiiCy  extending  from  the  junction  of  the 
neck  and  occiput  to  the  centre  of  the  bregma.  Measures  9.5 
cm.  (3|  inches). 

SubocGipitofrontal,  extending  from  the  junction  of  the  neck 


THE  FCETUS. 


83 


uikI  occiput  to  the  suininit  of  the  brow.     Measures  11  cm. 

(4jJ  iuclies). 

ll'qturidal,  measures  through  the  ceutre  of  the  parietal 
('inineuces.     Measures  9.0  cm.  (3.^^  inclies). 

l-'r(m(<)iiH')it((l,  exteiuliug  from  tlie  sumuiit  of  the  brow  to 
the  centre  of  the  lower  border  of  tlie  chin.     Measures  U  cm. 

(3,V  inches). 

^   ^  Fiu.  43. 


Vertex.    Left  occipito-posterior  position.    (Ribemont-Dessaigncs  and  Lepage.) 

Cervicobregmatic,  extending  from  the  junction  of  tlie  neck 
and  cliin  to  the  centre  of  the  bregma.  Measures  9.5  cm.  (3| 
inclies). 

The  above  diameters  (Figs.  38  and  39)  are  all  of  them 
more  or  less  compressible. 

The  remainder  are  incompressible. 

Bimastoid,  measured  through  the  mastoid  processes,  7  cm. 
(2f  inches). 


84 


OBSTETRIC  ANATOMY. 


Bimalary  measured  throiigli  the  malar  eminences,  7  em.  (2f 
inches). 

Ilitemporal,  measured  through  the  lower  extremities  of  the 
coronal  suture,  8  cm.  (.'3^  inches). 

The  follov^iufj  tnhle  is  suiliciently  accurate  for  all  practical 
purposes  and  should  be  memorized  : 

Fio.  44. 


Face.    Loft  mcnto-antorior  poKition.  (Farabeufand  Varnier.) 

Diameters  of  the  Foetal  Head  (Jeivett). 

Biparietal,  9  cm.  (3^  inches) 

Suboccipitobregmatic,  9  cm.  (3^     "  ) 

Frontomental,  9  cm.  (3|     ''  ) 

Occipitofrontal,  11.6  cm.  (4^     "  ) 

Occipitomental,  14  cm.  (5^     "  ) 


TIIJ'J  V(ETUS. 


85 


In  the  followinf;  taMo  the  circumferences  of  the  most  iin- 
jud-taiit  planes  of  the  f(et;il  liead  are  ^Hven  : 

Circumjerenvct*  of  tliv   Phinca  of  the  F<e(<tl  J  [aid. 

Siiho('<'i|)itol)re^nnatic,  .'^3  cm.  (l.'i  inches). 

Snboeeipitofrontal,  ;i5  cm.  (l.'i;|    "      ). 

Occipitofrontal,  34.5  cm.  (13^    "     ). 

Kio.  45. 


Face.    Right  mento-anterior  position.    (Farabeuf  and  Varnier.) 

Importance  of  flexion  of  foetal  head :  When  the  head  is  com- 
pletely flexed,  as  it  is  in  normal  labor,  its  smallest  plane 
(measured  by  its  circumference)  comes  into  relation  with  the 
different  pelvic  planes  successively  as  the  head  descends.    This 


86 


OJiSTJ'JTRIC  A  NA  TOM  Y. 


smallest  plane,  as  will  be  noticed  in  the  al)ove  talkie,  is  the  sub- 
o('('ipif()/)r<ynKi(ic.  The  importance  of  the  maintenance  of 
complete  flexion  of  the  fa'tal  head  until  almost  the  moment 
of  its  delivery  v/ill  tiius  be  easily  comprehended. 


Fig.  46. 


Face.    Uiglit  inonto-pohterior  position.    (Farabfuf  and  Vuniior.) 

Moulding  of  the  fcetal  head :  During  labor  the  head  under- 
goes more  v^r  k  is  com]  ressicn  w!iich  results  in  its  alteration 
in  shape. 

Mouldiiig  results  from  the  overlapping  of  the  (M-anial  bones, 
vliich  t  Ives  place  iu  a  definite  way  in  all  ca.ses.     The  parietal 


THE  F(ETIJS. 


87 


Ix.iu'S  override  tlie  occipital  and  frontal  bones;  and  of  the 
parletals  the  one  most  pressed  ii]>on,  generally  the  one  in  rela- 
tion to  the  promontory,  always  slips   nnder   the  other.     The 


Fia.  47, 


Face.    Lift  •uentD-postcrior  position.    (Fiirabtnif  and  VariiiiT.) 

itwo  halves  of  the  frontal  bone  follow  the  same  rule  as  the 
parietal  hones. 

Thi!  wliole  volnme  of  the  head  is  rediieed  bv  compression, 
tile  greater  j)oi'ti'  ii  of  the  cerebrospinal  Hiiid  and  of  tiie  con- 
tents of  th(!  cerebral  bloodvessels  being  forced  out  of  the 
cranial  cavity  during  labor. 


88 


OBSTETRIC  ANATOMY. 


The  foetal  trunk :  The  (Jiameters  of  inij)()rtance  in  the  trunk 
are  few,  as  tlie  whole  body  is  very  incompressible.  The  hi.s- 
(icroiaidl  is  the  longest  and  measures  12  cm.  (4|  inches),  and  is 
reducible  to  tlie  extent  of  2  to  3  cm. 

The  hitrnchfinteric  measures  about  10  cm.  (4  inches). 

The  dorsosternal  measures  9  cm.  (3|  inches). 

Fi«.  48. 


Breech     Left  .sacroanterior  position.    (Farabouf  and  Varnier.) 

Thv  f(')i(/th  of  the  fcetal  ovoid,  that  is,  from  the  vertex  to  the 
breech,  may  be  given  as  24-24.5  cm.  (9^  to  10  indies). 

Mobility  of  the  foetal  head  and  trunk :  The  movements  of 
flexion,  extension,  and  rotation  of  the  JwUd  hciid  are  of  great 
imjmrtance  in  the  mechanism  of  labor.  Flexion  is  limited  by 
the  pressure  of  the  chin  upon  the  chest. 


THE  FCETUS. 


89 


Extension  is  limited  by  compression  of  tlic  oeeiput  against 
tlie  back.  Jioddion  is  safe  tiiroiigli  an  are  of  90  decrees 
on  each  side,  till  the  chin  points  over  the  shonlder. 

The  trunk  permits  of  a  certain  anionnt  of  rotation  which  is 
limited  by  the  rotation  of  the  vertebral  bodies.     A  certain 


Fig.  49. 


Breech.    Right  sacro-anterior  position.    (Farabeuf  ami  Varnier.) 

('('irree  of  lateral  flexion  is  also  possible  as  Avell  as  ordinary 
He.xion  and  extension. 

The  posture  of  the  fetns  is  the  relation  which  the  trnnk, 
head,  and  limbs  of  the  child  have  to  one  another,  independently 
of  the  relations  of  any  part  of  the  fa'tus  to  any  part  of  the 
mother. 

The   normal  posture  of  the  fcetus  during   pregnan(!y  and 


90 


OBSTETRIC  A  NA  TOMY. 


piirtnrition  is  one  of  Hexion,  the  liead  heing  flexed  on  tlie 
trunk,  tlio  tliiglis  on  the  abdomen,  and  tlie  legs  on  the  tliiglis, 
the  amis  heing  fohled  on  tlie  ehest. 

The  relation  of  the  uterine  and  foetal  axes  :  Dnring  the  lattei* 
part  of  pregnane}'  and  in  partnrition  the  long  axis  of  the  i\vU\\ 
ovoid  may  eorresj)ond  to  the  long  axis  of  the  uterus  (longi- 
tudinal) J  or  may  be  at  right  angles  to  it  (transverse). 

Fig.  60. 


lirioch.    Kiglit  sacro-posterior  position.    (Farubeuf  and  Vaniicr.) 

NontutJIji  the  long  axes  {'orresp')iid  ;  any  deviation  from  this 
relationshij)  leads  to  serious  coinplie;itions  i!i  labor. 

(  ommonly,  obstetrieians  aj)j)ly  tiie  term  presentation  to 
denote  the  relation  of  the  long  axis  of  the  fcetal  ovoid  to  the 
uterine  axis.     In  our  opinion  the  use  of  this  term  to  denot<' 


THE  FCETUS. 


91 


this  rolationsliip  is  a  misnomer.  The  term  prcficntation  should 
onlv  he  used  to  denote  tlie  part  of  the  lu'tus  which  presents  at 
the' pelvic  hrim  and  is  accessible  to  the  examining  Hnger. 

Presentations:    Under  the  definition  just   given  there  are 
three  forms  of  fa;tal  presentation  :  the  ccplialicy  i\\G  iielvicy  and 

Fi(i.  51. 


Bnccli.    l.t'ft  saiTu-ixisttTior  jKisition.     (Farabeuf  and  Varnicr.) 

the  soiiKifir.     There  occur  distinct  varieties  of  each  of  these 
forms,  as  will  be  noted  in  the  following  table  : 

T((b(('  of  Fa:f<d  Presentations. 
Frequency, 

1)7  i)er  cent. — {<i)    vertex,       [h)  face,        (c)  brow. 
1.0  per  cent. — (^0    breech,       {h)  leg,         (c)  foot. 


( 'ej)h((I!e, 

Peh'ie, 

SoiiHttie, 


0.5  per  cent. — i>t)    shoulder,   (h)  elbow,    (c)  hand. 


02 


OBSTETlilG  ANA TOMY. 


Tlin  hiftvr  form  of  presentation  is  often  termed  transverse  or 
crossed  birth. 

Position:  Tiie  pelvic  brim  is  divided  l)y  tlie  conjugate  and 
transverse  diameters  into  Jour  qtiddraiif.^.  Position  may  be 
defined  as  the  relationship  of  the  presenting  part  of  the  fwtus 
to  the  quadrants  of  the  pelvic  brim.     Thus  for  each  presentu- 

Fio.  52. 


Shoulder.     Left  sonimlo-nntcrior  jiositidn.     (Farabeuf  and  Varnicr.) 

tion  there  arc  four  positions.  They  are  named  according  to 
the  ])articular  quadrant  confronted  by  the  [)resenting  ]wrt. 

In  vertex,  face,  and  breech  presentations  the  long  diameter 
of  the  presenting  part  engages  in  (.>ne  of  the  oblique  diameters 
of  the  pelvic  inlet. 

In  vertex  presentations  when  the  occiput  confronts  the  left 


.V 


THE  FCKTUS. 


93 


antorior  quadrant  of  the  pelvic  brim,  tlio  pofiitlon  is  loft 
(K'oipit()-aiit(MMor,  and  so  on. 

luii-c  prcKcidiit'unin  arc  named  similarly  according  to  tlio 
direction  of  the  chin,  left  niento-anterior,  etc. 

Ilrcri'h  ptu'soitdfions  are  named  according  to  the  position  of 
the  sacrum,  left  saero-anterior,  etc. 

Fi(i.  53. 


Shnuldcr.    Ri,i,'lit  seai)nlf)-aiitori()r  position.     (Farabcuf  luid  Viiriiii'r.) 

>'^ho}d<h't'  prcscufdfioiii^  are  named  according  to  the  direction 
of  the  scapula,  left  scapnlo-anterior,  etc. 

The  positions  are  sometimes  spoken  of  as  first,  second,  third, 
or  fourth,  the  left  anterior  being  the  first  and  the  others  fol- 
lowing in  order  from  left  to  right  around  the  pelvic  brim. 
This  method  is  apt  to  mislead,  as  various  authorities  differ  as 
to  which  is  the  first  position  in  certain  presentations,  and  con- 


94 


OBSTETRTO  ANATOMY. 


fusion  results.     Tt  is  better  to  desigjnate  each  position  in  full 
or  by  the  initial  letters  (Figs.  40-55). 


Fig.  54. 


Shoulder.    Right  scapulo-posterior  position.     (Ftirubuuf  und  Variiier.) 

Vertex  positions : 

Left  occipito-anterior,  L.  O.  A. 
Right  occipito-anterior,  R.  O.  vV. 
Right  occipitoposterior,  R.  O.  P. 
Lef^  occipitoposterior,  L.  O.  P. 

Face  positions : 

Left  mento-anterior,  L.  M.  A. 
Right  mento-anterior,  R.  M.  A. 
Right  mentoposterior,  R.  M.  P. 
Left  mentoposterior,  L.  INI.  P. 


THE  FCETUS. 

Breech  positions  : 

lii'I't  sacro-iintcrior,  L.  S.  A. 
IJi<;Iit  sacro-antt'i'ior,  11.  S.  A. 
KiL'lit  sa('r(>j)()sU'ri()r,  \l.  S,  1*. 
jjot't  sacroposterior,  L.  H.  P. 

Somatic  or  shoulder  presentations  : 
Left  s('a|>iilo-ant(>rior,  L.  Sc.  A. 
Ixiii'lit  scapiilo-autcrior,  R.  Sc.  A. 
Iii<i:Iit  s('a})iiloj)os(c'rior,  Jv.  Se.  P. 
licf't  scapiilojK)stori()r,  L.  Sc.  P. 

Fjo.  55. 


95 


Shoulder.    Left  scapulo-posterior  position.    (Ftiriilicuf  and  Variiiur.) 

Face  presentations  are  .soinetinies  named  according  to  the 
|)(lvic  (quadrant  confronted  by  the  brow,  as  left  fronto-anterior, 
L.  F.  A.,  etc. 


lii 


9G   THE  MECHANISM  AND  COURSE  OF  NORMAL  LABOR. 

Tliat  soiiio  form  of  cephalic  presentation  occurs  in  97  per 
cent,  of  all  cases  is  not  <juite  satisfactorily  accounted  for. 
There  ar<!  three  conditions  each  of  which  lias  some  inHuence 
in  l)rin^in<j:  about  this  result.  These  ar(! :  1,  the  positi(>n  of 
the  centre  of  gravity  of  the  fietus ;  2,  the  relative  shapes  of 
the  uterus  and  of  the  f<etus  ;  3,  the  njovements  of  tlie  fcetus  : 

1.  Matthews  Duncan  long  ago  found  that  the  centre  of 
gravity  of  the  foetus  lay  somewhere  about  the  shoulders,  and 
nearer  the  right  than  the  left,  owing  to  the  presence  of  the 
liver  on  the  right  side.  Thus  if  a  fetus  is  immersed  in  a 
saline  fluid  of  the  same  specific  gravity  as  its  own,  it  sinks 
into  a  position  with  the  back  of  its  right  shoulder  looking 
downward,  this,  therefore,  becoming  the  lowest  part  of  the 
body. 

2.  The  relative  shapes  of  the  uterus  and  of  the  foetus :  The 
fundus  is  at  term  the  most  roomy  part  of  the  uterus;  hence 
at  term  the  more  bulky  breech  finds  greater  accommodation  in 
the  upper  segment,  while  the  head  readily  adapts  itself  to  the 
smaller  lower  segment. 

The  foetal  movements :  The  movements  of  the  legs  of  the 
fetus  are  })rol)al)ly  more  ])owerful  than  those  of  the  arms. 
Hence  if  the  child  lie  with  the  feet  downward  these  will 
when  in  a  state  of  motion  come  into  contact  with  the  resist- 
ing ])elvic  brim,  which  will  result  in  lateral  displacement  of 
the  child's  body.  The  shaj)e  of  the  uterus  will  then  tend  to 
convert  this  attitude  again  into  a  longitudinal  one.  The 
action  of  the  specific  gravity  of  the  foetus  will  tend  to  bring 
the  cepliali(!  pole  downward,  and  when  once  this  position  ha> 
been  obtained  its  alteration  is  not  likely  to  occur  provided  no 
abnormal  conditions  are  present. 

THE  MECHANISM  AND  COURSE  OF  NORMAL 

LABOR. 

Definition :  The  term  cutocia,  indicating  normal  labor,  is 
applied  to  labors  which  terminate  \vithout  artificial  aid  and 
without  injury  to  the  mother  or  child. 

Under  this  definition,  in  this  work,  only  uncomplicated 
vertex  presentations  will  be  classed  as  normal. 

At  this  point  it  may  be  mentioned  that  a  woman  pregnant 


TUi:  r.ir.s'/'.'.s'  of  the  osset  of  lauor.  \)7 

I'lir  tlic  first  time  is  ItTinod  a  jtrinilf/roridd  ,-  one  in  labor  or  in  .  ' 

the  pncrjx'riuiM  tor  tiu'  first  linic,  a  inhiiijtitrd.  ' 

It' a  woman  lias  lia«l  several  cliildrcn  or  miscarriages  pre-  ij  | 

viuiislv  slie  is  termed  a  iiniffij»<ii-(f.      When   it   is  doiivd  to  in-  '' 

(licate  the  exact   lunnhei'  ot"  the   labor  she   is  spoken  of  as  a 
i  para,  ii  para,  iii  para,  and  so  on.  '' ! 

Stages  of  labor :   While  there  is  treqnently  a  i)remonitory  ; 

-tauo  before  labor  aetnallv  sets  in,  it   i>  enstomary  to  divide 
hibor  itself  into  three  distinct  sta«»'es  : 

The  first  sfof/c,  or  stage  of  dilatation,  ends  with  the  fnll 
(lilatati(tn   of  the  os  nteri,    with    which   the   rnpture  of  the  j 

membranes  is  usnally  coincidctnt. 

The  second  sf(t(/c,  or  stage  of  expnlsion,  ends  with  the 
complete  birth  of  the  child. 

'J'lie  third  st<t(/<.,  or  ])laeental  stage,  ends  with  complete 
expulsion  of  the  j)lacenta  and  membranes  and  retraction  of 
the  uterus. 

'f he  duration  of  normal  labor :  The  average  duration  of 
normal  labor  in  primi))ara'  may  bo  stated  as  eigliteen  hours  ;  ;■  •! 

while  in  multipara'  it  is  from  eight  to  ten  hours. 

The  average  duration  of  the   first   st<i(/c  in    primiparte    is  -, 

a!)out  twelve  hours;  in  multipane  from  six  to  eight  hours.  I 

Tiu.'  second   st<i(/e    in    primipane    lasts  about   four    to   six  i 

hours;  and  in  nndtij)ara'  from  one  to  two  hours.  j 

The  third  .stac/e,  Mhich  is  but  rarely  terminated  spontane- 
ously, lasts  from  a  few  minutes  to  two  hours. 

The  Causes  of  the  Onset  of  Labor. 

No  entirely  satisftictory  tlieory  has  been  advanced  to  ac- 
count for  the  onset  of  labor,  which  usually  occurs  on  the  two 
hundred  and  eightieth  day  after  the  beginning  of  the  last 
nun>trual  period. 

it  is  known  that  three  motor  centres  exist  which  preside 
over  uterine  contractions;  a  centre  in  the  medulla  ;  the  cervi- 
cal ganglia;  and  the  ganglia  in  the  anterior  vaginal  wall  and 
the  uterine  walls. 

Labor  is  not  the  result  of  the  operation  of  one,  but  rather 
of  a  number  of  concurrent  causes.  These  act  In'  increasing 
the  painless  rhythmic  contractions  of  tiie  uterus  present 
thruugliout  tlie  whole  period  of  pregnancy. 

7— Obst. 

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98    THE  MECHANISM  AND   COURSE  OF  NORMAL  LABOR. 

The  following  are  among  the  most  probable  causes  :^ 

1.  Loosening  attachment  of  the  ovum,  thus  converting  it 
into  a  foreign  body  ; 

2.  Excess  of  carbon  dioxide  in  the  blood  ; 

3.  Distention  of  tiie  uterus  by  the  ovum  ; 

4.  Mental  impressions. 

1.  Loosening  attachment  of  the  ovum:  It  has  l)eon  observed 
that  toward  the  end  of  pregnancy  the  trabecular  in  the  spongy 
layer  of  the  decidua  vera  decrease  in  size,  causing  this  layer, 
as  it  were,  to  shrivel  up,  and  thus  easy  separation  of  the  ovum 
is  permitted.  Also  slight  hemorrhages,  wh'  h  occur  as  tiie 
result  of  violent  uterine  contractions,  tend  to  '  in  detaching 
the  ovum  from  tlie  uterine  walls.  The  ovum  tnus  becomes  a 
foreign  body  and  excites  the  uterus  to  further  action. 

2.  Excess  of  carbon  dioxide  in  tho  blood:  As  the  fwtsis 
develops  it  demands  i«.  nourishment,  and  there  is  at  the 
same  time  an  increase  in  its  tissue-waste,  M'hich  includi-s 
carbon  dioxide.  This  gas  has  been  proved  by  Brown-Sequard 
to  excite  uterine  action  by  stimulating  the  nerve-centres  men- 
tioned above. 

Certain  changes  are  supposed  to  take  place  in  the  placenta 
leading  to  an  increase  in  the  (juantity  of  carbon  dioxide. 
When  the  venous  blood  has  accunuilated  a  hufticient  quantity 
of  this  gas,  uterine  contractions  are  stimulated  to  such  an 
extent  that  labor  is  established. 

3.  Distention  of  the  uterus:  All  hollow  viscera  when  dis- 
tended to  a  certain  limit  contract  and  expel  their  contents. 
Witness  the  distention  of  the  bladder,  the  rectum,  and  the 
overloaded  stomach  of  the  infant. 

4.  Mental  impressions :  The  emotions  play  a  large  j)art  fre- 
quently in  inducing  uterine  contractions.  (Jreat  grief,  joy,  or 
severe  fright  experienced  toward  the  end  of  ])regnaucy  fre- 
quently precipitate  labor. 

The  Forces  of  Labor. 

The  expellent  forces  of  labor  are  : 

1.  Contractions  of  the  uterus  and  of  the  vaginal  and  pel- 
vic muscles ; 

2.  Contractions  of  the  abdominal  nuiscles  and  diaphragm  ; 

3.  Gravity. 


CONTRACTIONS  OF  THE   UTERUS,  ETC.  99 

1.  Contractions  of  the  Uterus  and  of  the  Vaginal  and  Pelvic 

Muscles. 

Uterine   Contractions, 

These  are  by  far  the  most  important  factor  in  bringing 
•ihoiit  the  expulsion  of  the  ovnm. 

riie  contractions  are  involuntary,  ocmrring  iiuh'pcndcntly 
(.1"  the  woman's  will  ;  tliough  they  nndonbtedly  are  weakened 
i\v  even  iidiibited  by  varions  agents.  Emotion,  such  as  the 
(head  of  pain,  or  nervonsness  caused  by  the  entrance  of  the 
|(hv>ician  or  a  stranger,  may  inhibit  them.  A  loaded  rectnm 
or  a  full  bladder  may  reflexly  inhibit  nterine  contractions. 

They  are  peristaltic,  the  wave  of  the  contraction  being  from 
the  fimdns  to  the  cervix,  and  lasting  from  one-third  to  two- 
thirds  the  length  of  the  labor  pain. 

They  are  intermittent.  The  contraction  begins  gradnally, 
rapidly  reaches  an  acme,  and  tlien  slowly  j)assos  off.  This 
may  be  demonstrated  clinically  by  keeping  the  hand  on  the 
woman's  abdwminal  wall  thronghont  a  contraction  ;  the  nterns 
will  be  felt  to  harden  gradnally  ;  then,  remaining  in  this  con- 
dition for  a  short  interval,  to  relax  and  b,ecome  soft  again. 

Their  duration  averages  abont  one  minnte.  In  the  earliest 
stage  of  labor  they  occnpy  but  a  few  seconds  ;  bnt  in  the  ex- 
pulsive stage  they  last  longer  and  are  stronger.  The  con- 
I pactions  are  rhythmical  in  their  intermissions.  There  is  a 
certain  regnlarity  in  their  appearance  and  disappearance.  The 
i:i'<'ater  their  freqnency  the  longer  their  duration.  At  the 
l)('ginning  of  labor  the  interval  is  long,  say  a  (piarter  of  an 
hour;  toward  the  end  the  interval  between  the  pains  may  be 
l»iit  a  few  seconds,  so  that  the  contractions  seem  to  be  almost 
continuous. 

The  contractions  are  painful,  hence  the  term  "  pains " 
usually  apjdied  to  them.  This  pain  is  due  to  the  forcible 
^•tictching  of  the  cervix  and  its  attachments,  and  of  the  vagina 
and  vulva  consecutively  ;  also  in  j>art  to  the  fact  that  the 
uterus  is  contracting  against  resistance.  A  parallel  to  this 
latter  occurs  in  the  intestine  when  an  obstruction  exists.  The 
pain  is  usually  referred  to  the  sacral  region,  especially  in  the 
earlier  stages;  later,  when  the  sacral  nerves  are  pressed  U])on 
by  the  advance  of  the  foetus,  the  pain  is  felt  down  the  limbs. 


100  THE  MECHANISM  AND  COURSE  OF  NORMAL  LABOR.  | 

The  individual  musde-jihrcs  of  the  uterus  during  contryction         I 
become  shorter  and  thicker  than  they  are  during  relaxation. 

Retraction  is  a  process  peculiar  probably  to  all  involuntary 
muscle-fibres ;  but  is  most  marked  in  those  of  the  uterus. 
Retraction  enables  a  muscle-fibre  which  has  shortened  dur- 
ing contraction  to  relax  without  returning  to  its  original 
length.  The  fibres  after  contraction  do  not  quite  return  to 
their  original  length,  but  remain  persistently  somewhat  shorter 
and  thicker. 

Retraction  is  due  in  part  also  to  a  rearrangement  of  tlu; 
fibres.  These  are  assumed  at  the  beginning  of  labor  to  be 
nearly  end  to  end  ;  in  the  course  of  retraction  they  come  to 
lie  almost  side  to  side.  J^etraction  is  practically  limited  during 
labor  to  the  muscle-fibres  forming  the  upper  idcrine  .scc/vwiif. 
This  portion  of  the  uterine  wall  as  the  ovum  is  ])ushed  down 
becomes  gradually  thicker ;  thus  its  propulsive  force  during 
contraction  augments,  and  it  is  enabled  to  remain  constantly 
in  contact  with  the  upper  end  of  the  ovum  until  its  expulsion 
from  this  segment. 

The  hnrer  vtcrlne  segment^  not  possessing  the  power  of  retrac- 
tion, becomes  progressively  thinner  and  dilates  as  the  ovum  is 
forced  down  through  it.  Retraction  thus  enables  the  uterus 
to  preserve  the  exj)ulsive  results  of  contraction. 

Polarity  is  a  useful  term  to  express  the  fact  that  throughout 
labor  the  expelling  part  of  the  uterus — the  up])er  segment — is 
in  a  state  of  opposite  function  to  the  sphincter  part — the 
lower  se;z:ment  and  cervix. 

During  ])regnancy  the  muscle  forming  the  l)ody  of  tlic 
uterus  is  practically  at  rest,  while  the  cervix,  especially  the 
internal  os,  is  in  a  state  of  tonic  ccmtraction,  it  is  active. 
During  labor  this  relation  is  inverted,  the  body  contracts 
while  the  cervix  is  relaxed.  This  relation  is  takei  advantage 
of  when  it  is  necessary  to  induce  labor  for  any  cause — that  is, 
to  set  up  active  contractions  in  the  muscle  forming  the  body 
of  the  uterus.  This  is  usually  accomplished  by  dilating  the 
cervix  either  manually  or  by  instruments,  which  brings  about 
the  desired  result. 

Effect  of  uterine  contractions:  In  chaiH/hig  the  ,shapc  (t)i(l 
])<)f<itlo)i  of  iltc  utci'Ui^:  During  a  contraction  the  longitudinnl 
and  anteroposterior  diameters  of  the  uterus  t're    increased, 


(VyTRACTION  OF  THE  AJiDOMlXAL   MUSCLES,   ETC.   101 

wliilo  itrs  transverse  diameter  is  decreased,  tlie  whole  organ 
M-snininu:  a  rou»j:;hly  cylindrical  form  (see  also  pp.  38  and  'W). 
Tlio  fundus  is  held  ai^ainst  the  ahdoniinal  wall  and  hecomes 
more  prominent  ;  this  brinj^s  the  Ion*:;  axis  of  the  uterus  into 
line  with  that  of  the  inlet  of  the  pelvis. 

()i\  tlic  ch'i'uhit'Km  in  the  iiicru.s  (did  pltK'ciiUi:  I )urin<^  con- 
traction the  uterine  sinuses  are  slowly  obliterated  and  emptied, 
rcfilliuu-  as  it  passes  off;  hut  the  i\vta\  jHU-tion  of  the  placenta 
i>  not  alfected.  Thus  throuu;hout  the  whole  of  pre*;'nancy  tiie 
circulation  of  blood  in  the  uterus  is  assisted  by  the  regular 
ihvthmical  uterine  contractions. 

Oh  thcfivtal  heart:  The  fcetal  heart  is  slowed  because  the 
pressure  on  the  placental  site  raises  the  general  fetal  blood- 
pressure. 

On  the  iiKifenHi/  pii/.se :  The  maternal  j)ulse-rate  increases 
ten  to  twenty  beats,  thus  contrasting  with  the  f(jetal  pulse- 
rate. 

Vaf/iu((/  (did  Pelvic  3fu.selefi. 

These  muscles  play  but  a  very  unimportant  part  in  bring- 
ing about  the  expulsion  of  the  ovum.  They  act  only  in  the 
later  stages. 


2.  Contraction  of  the  Abdominal  Muscles  and  Diaphragm. 

The  muscles  entering  into  the  formation  of  the  abdominal 
walls,  along  with  the  diaphragm,  wh'Mi  simultaneously  in  a 
state  of  contraction,  increase  the  intra-abdominal  j)ressure  and 
thus  render  very  important  aid  to  the  uterus.  The?se  muscles 
taken  altogether  form,  as  it  were,  a  second  layer  of  nuiscular 
ti--ue  external  to  the  uterus. 

Their  mode  of  action  is  as  follows  :  A  deep  ins|>iration  is 
taken,  thus  flattening  out  and  depressing  the  diaphragm, 
w  hich  is  then  fixed  by  the  closure  of  the  glottis  ;  then  the 
muscles  in  the  abdominal  walls  contract.  The  descent  of  the 
diaphragm  pushes  the  fundus  forward;  this  is  resisted  by 
the  contraction  of  the  muscles  of  the  abdominal  wall,  so  that 
the  resultant  of  the  combined  pressure  of  these  muscles  is  in 
the  direction  of  the  long  axis  of  the  uterus — that  is,  down- 
ward in  the  axis  of  the  pelvic  brim. 


102  THE  MECHANISM  AND   COURSE  OF  NORMAL  LABOR. 

The  action  of  tlioso  muscles  is  not  exerted  until  the  second 
or  expulsive  sta<^e,  and  is  at  first  entirely  voluntary.  Jn  the 
later  stages  of  the  expulsive  period  their  action  is  entirely 
involuntary. 

At  first  they  act  only  during  the  acme  of  a  ])ain,  when  the 
woman  voluntarily  hears  down  ;  hut  later,  when  the  pain 
lasts  longer,  the  woman  is  compelled  to  o})en  the  glottis  to 
respire,  thus  I'elaxing  the  j)ressure  ;  hut  innnediately  another 
hreath  is  taken,  they  act  again,  so  that  there  are  often  several 
abdominal  contractions  to  one  pain. 

3.  Gravity. 

The  weight  of  the  child  and  of  the  waters  contained  in 
the  niemhranfts  exerts  but  a  small  influence  in  ding  ex- 
j)ulsion,  except  perhaps  during  the  first  stage  of  lauor,  when 
the  woman  is  more  or  less  in  the  erect  or  semirecumbent 
position. 

LABOR— FIRST   STAGE. 

Premonitory  Signs  and  Symptoms  of  Labor. 

The  events  which  indicate  the  approach  of  labor  are  varia- 
ble in  their  duration  and  may  be  so  slight  as  (piite  to  escape 
observation. 

The  change  of  position  of  the  uterus  which  takes  place 
during  the  last  weeks  of  pregnancy  has  been  referred  to 
already. 

Irregular  pains,  usually  felt  low  down  in  the  abdomen  in 
front,  are  frequently  complained  of  by  patients  for  some  days 
before  the  onset  of  true  labor.  They  are  sometimes  severe, 
and  may  cause  nuich  suffering  to  sensitive  women.  These 
"false  pains,"  as  they  are  termed,  may  be  distinguished 
from  true  pains  by  their  irregularity  and  by  their  site  ;  true 
labor-pains  being  felt  chiefly  in  the  sacral  region.  These 
false  pains  have  absolutely  no  effect  on  the  cervix,  and  no  in- 
crease in  the  vaginal  secretion  accompanies  them. 

Frequency  of  micturition  and,  less  often,  of  defecation,  niiiy 
be  troublesome  during  the  last  few  days,  and  are  probably 
caused  by  increase  in  the  nervous  excitability  of  the  pelvic 
structures  usually  present  at  this  time. 


MECHANISM   OF  THE  FIIiST  STAGE. 


10:3 


Characteristic  Signs  and  Symptoms  of  the  Onset  of  Labor. 

Regular  uterine  contractions:  Tlic  interval  iH'twccn  tlu'se  is 
loiiu'  at  first,  but  sliortcns  steadily  as  the  labor  in-ourcsses. 
The  j)alns  at  this  period  are  always  referred  to  the  sacral 
rcnioii. 

Appearance  of  the  "show":  This  is  the  term  eonunonlv 
;i|»]>lied  to  the  imieiis  tinged  witii  blood  which  escajx's  IV(  in 
the  cervix  and  vagina  at  this  time.  The  mnciis  comes 
I  hiclly  from  the  cervix,  and  the  blood  fr(»m  the  separated 
-urfaces  of  the  membranes  and  the  uterine  walls  just  above 
the  internal  os. 

Softening  and  shortening  of  the  cervix :  These  changes  can 
only  be  noticed  by  making  a  vaginal  examination.  The 
softening  of  the  cervix  is  due  to  infiltration  with  serous  exu- 
date resulting  from  the  interference  with  the  return  circula- 
tion caused  by  the  uterine  contractions.  'I'he  shortening  of 
tlic  cervix  results  from  tlie  yielding  of  the  internal -os,  whicii 
is  undoubtedly  a  physiological  relaxation  analogous  to  that 
which  takes  place  in  sphincter  nuiseles. 

Mechanism  of  the  First  Stage. 

The  uterine  contractions  during  this  stage  are  occupied  en- 
tirely with  dilating  the  cervix,  there  being  little  or  no  expulsion 
of  the  ovum,  this  being  limited  to  the  slight  advance  of  the 
i)a<:'  of  membranes  throuii:!!  the  internal  os. 

Dilatation  of  the  cervix  results  from:  (1)  the  yielding  (.f 
tjic  internal  os,  which  is  a  physiological  relaxation  ;  (2)  the 
hydrostatic  pressure  of  the  bag  of  waters  ;  and  (3)  the  action 
of  the  lomr  muscular  fibres  in  the  outer  muscle-laver  of  the 
uterus. 

1.  The  first  of  these  lias  already  been  discussed. 

2.  The  hydrostatic  pressure  of  the  bag  of  waters:  The  first 
result  of  uterine  contraction  is  an  i)i(')r((f<c  in  fJic  r/ciicvdl  iittnt- 
iih-rine  fluid  prc'tsurc.  AVhen  the  waters  are  abundant  and 
the  membranes  intact  the  effect  of  this  pressure  is  nil  ^o  far 
as  the  ffvtus  is  concerned,  as  the  law  of  fluid  pressure  is  that 
it  is  equal  and  opjiosite  in  all  directions. 

The  (Urcrtioii  of  the  force  of  the  uterine  contraction  is 
centripetal;  this  is  oj)posed  eentrifugally  by  the  bag  of  waters. 


104  THE  MECHANISM  A^D  COURSE  OF  NORMAL  LABOR. 

The  foiro  of  tlio  contraction  is  centripetal,  wliile  tlio  force 
exerted  hy  the  haj^  of  waters  in  opposition  is  ci'iitrifujjjal. 

These  two  forces  would  lluMi  <(/i>(;Iizr  one  (iiiofhcr  if:  (I) 
the  utei'ine  wall  were  of  e(|iial  thickness  throu<j:hont,  and 
therefore  of  e(pial  strenirth  throughout;  and  if  (*i)  the  uterine? 
wall  were  in  a  state  of  ecpial  contraction  throut;hout  at  tiie 
same  moment  of  time. 

/>(>l/i  l/icsc  coiHlifioiis  fdif  in  that :  Jir^f,  the  uterine  wall  is 
not  of  e([ual  thickness  throui;houl,  the  lower  se<i-ment  heinj:; 
thinner;  and  havintr  a  solution  in  its  continuity  (the  yieldin^j,- 
internal  os),  it  is  weaker  and  therefore  must  expand  ;  f^ccond/i/, 
the  uterine  wall  is  not  in  a  state  of  eijual  contraction  throui:;h- 
out  at  the  same  moment  of  time,  in  that  the  contraction  is 
vermicular,  heginninj^  at  the  fundus  and  s[)readinf^  downwanl 
to  the  cervMx,  so  that  when  the  fundus  is  in  a  state  of  con- 
traction the  cervix  is  relaxed.  This  may  be  demonstrated 
clinically  by  keeping  the  finger-tip  on  the  lowest  point  of  the 
bag  of  waters,  when  at  the  onset  of  a  pain  this  will  be  felt  to 
})econic  tense  some  seconds  before  the  woman  comj)lains  of 
the  pain  which  causes  the  increase  of  ])rossure. 

For  these  reasons  the  force  of  the  centrifugal  pressure  of 
the  waters  is  exerted  most  markedly  on  the  lower  uterine 
segment  and  cervix  ;  hence  (li/<d<(tion  of  tJiese  parts  takes  j>lace 
as  a  result  of  the  increase  in  the  general  intra-uteriue  fluid 
pressure. 

Afi  (llf((f(ifion  proeeedfi  the  membranes,  having  become 
loosened  from  their  attachment  to  the  uterine  walls,  insinuate 
themselves  into  the  opening.  Since  the  fluid  within  the  mem- 
branes transmits  the  force  of  the  uterine  contraction  ecpially  in 
all  directions,  the  bag  of  waters  is  distended  laterally  as  well 
as  downward,  thus  exerting  an  expansive  action  directly  on  the 
walls  of  the  cervix,  and  finally  on  tiie  margins  of  the  external 
OS.  As  the  cervix  and  external  os  dilate  this  lateral  pressure 
of  the  bag  of  waters  increases  proportionately. 

3.  The  action  of  the  longitudinal  muscle-fibres  of  the  uterus : 
The  contents  of  the  uterus  being  practically  incompressible, 
the  [)ull  of  the  longitudinal  fibres  will  result  in  drawing  the 
lower  uterine  segment  and  cervix,  who<e  structure  is  thinner 
than  thai  of  the  upper  segment,  up  over  the  contained  body. 
In  this  action  the  oblique  fibres  assist  to  a  considerable  extent. 


MECILiyJ^M   OF  THE  FIRST  STAaE.  105 

Tlio  wave  of  contraction  prol)al)ly  passes  tlirou<i:li  tlic  lonjii- 
iiidinal  lihrcs  more  ra[)i(lly  than  tliroULrli  tlic  <'ircu!ar  fibres, 
lu'iico  the  former  will  tend  to  draw  the  cervix  np  over  the 
itresentin^  })art  while  the  lower  segment  is  relaxed. 

When  the  cervix  and  external  os  have  become  well  dilated 
the  membranes  usually  rupture.  This,  as  a  rnle,  occnrs  dnrin<;' 
a  |)ain,  and  is  annonnced  l»y  a  gnsh  of  waters  from  the  va<>ina. 
The  (|iiMntity  eseapin<jf  will  depend  on  how  rapidly  the  i)re- 
Miitino-  part  of  the  f<etus  descends  and  o(tehides  tlu;  lower 
utei'ine  seji:;ment. 

The  rnj)tnre  of  tlie  membranes  may  occur  at  or  before  the 
(inset  of  labor ;  or  may  not  take  place  till  the  end  of  the 
expnlsive  stage;  bnt  it  is  very  rare  that  a  full-term  child  is 
horn  with  the  nuMnbranes  unruptured;  though  it  has  hap- 
jKiied  that  in  preci})itate  labors  the  whole  ovum  has  come 
away  entire. 

On  the  rupture  of  the  bag  of  waters,  the  presenting  part  of 
the  foetus  takes  its  place  as  a  dilator.  The  Huid  still  retained 
in  ntero  then  transmits  the  eft'eetive  intra-uterine  j)ressure  to 
that  jiortion  of  tlu;  fcetus  in  cont'<ci  v\  itii  the  margins  of  the  o-^. 

In  dry  labors — i.e.,  in  cases  where  the  membranes  rupture 
prematurely,  thus  permitting  the  escape  of  the  waters  before 
dilatation  has  progressed  to  any  extent — the  first  stage  of  la!)or 
becomes  tedious,  for  the  reason  that  no  part  of  the  firtus  can 
act  as  a  dilator  so  satisfactorily  as  tin;  hvdrostatic  i)ressure 
exerted  bv  the  bap:  *>f  waters.  In  these  cases  the  lon<r  fibres 
of  the  uterus  practically  <lraw'  the  cervix  uj)  over  the  wedge- 
like presenting  ])art  of  the  f(etus,  whatever  that  part  may  be. 

These  longitudinal  fibres  when  in  a  state  of  contraction 
produce  a  downward  traction  of  the  fundus  upon  the  fetus 
lending  to  force  it  downward  ;  this  force  is  transmitted  to  the 
presenting  part,  in  vertex  or  in  breech  cases,  by  the  vertebral 
column  of  the  child. 

This  downward  traction  of  the  fundus  exerted  by  the  longi- 
tudinal fibres  when  in  a  state  of  contraction,  does  not  cause  a 
drawing  down,  or  descent,  of  the  fundus  uteri,  because  the 
circular  fibres  by  their  more  ])owerful  action  tend,  as  it  were, 
to  straighten  out  the  somewhat  bowed  f(ctus ;  with  the  result 
that  the  position  of  the  fundus  in  relation  to  the  abdominal 


lOG  Till':  M  ECU  Ay  ISM  AND   COURSE  OF  yoiiMAL   LABOR. 

Mall  throughout  lal)or  docs  not  vary  ;  but  the  wholt;  resultant 
of  the  forces  exerted  hy  the  contractions  of  these  two  sets  (»f 
fibres  is  transnutted  down  tiie  vertei)ral  colunui  of  the  fo'tus  to 
the  pn  -enting'  part,  which  is  thus  foi'ced  to  advance,  wliile 
at  the  same  time  the  cervix  is  dilated  and  drawn  nj)  over  it. 

Os  uteri  during  first  stage  of  labor:  On  making-  a  vaginal 
examination  very  early  in  labor,  in  a  [n-'imipura,  that  })()rti(>M 
of  the  cervix  not  yet  taken  up  may  be  felt  as  a  soft  apju'ndagc 
to  the  spherical  surface  of  the  (listended  lower  ])ole  of  the 
uterus.  l*ossil)ly  the  external  os  may  be  sufficMcntly  solt  and 
dilated  to  j)ermit  the  insertion  of  the  Hnger-tip.  tinder  the 
same  circumstances  in  a  inultipdrd  the  os  may  be  quite  patent 
long  before  the  cervix  is  taken  uj),  so  that  the  finger  may 
easily  be  inserted  into  the  uterus.  Tnder  these  circumstances 
the  only  way  to  be  certain  of  the  extent  of  cervix  still  remain- 
ing to  be  taken  up  is  to  insert  the  linger  till  the  membranes 
can  })e  felt,  then,  while  withdrawing  it  making  firm  ])ressure 
on  the  ]X)stcrior  wall,  note  the  length  of  cervix  before  the  mar- 
gin of  the  cxt(;rnal  os  is  reached. 

Later,  when  the  cervix  is  completely  taken  up,  during  a 
pain  the  sharp  edges  of  the  external  os  can  be  ^^'><tinguishe(l, 
and  the  smooth  surface  of  the  membranes  can  be  felt  stretch- 
ing across  the  ai)erture. 

In  primipara  the  edge  of  the  external  os  is  at  first  thin  and 
sharj) ;  later  it  becomes  more  anlcmatous.  In  nndtipara  it 
may  be  thick,  and  as  a  result  of  laceration  in  a  ])revious 
labor  the  external  os  may  have  a  very  irregular  shape. 

The  degree  of  dilatation  may  be  described  by  stating  that 
the  OS  will  admit  one,  two,  or  three  fingers  ;  or  it  may  be  com- 
pared with  the  size  of  a  ten-cent  piece,  quarter,  etc. 

Clinical  Phenomena  of  the  First  Stage. 

Th(i  initial  labor-pains  come  on,  as  a  rule,  in  the  earlier  ])art 
of  the  night;  and  they  differ  but  little  from  the  false  pains, 
exce])t  that  they  occur  more  regularly  and  gradually  increase 
in  strength  and  frequency. 

The  j)ains  are  sharp  and  nagging,  many  patients  finding 
them  more  difficult  to  bear  tlian  those  of  the  expulsive  stage. 
Many  prefer  to  walk  restlessly  about,  bending  over  a  chair 


MECHANISM  oF  THE  SECOND  STAGE.  107 

or  tlie  f(K)t  of  tlic  bed  diirini:;  tlic  acme  of  the  pain,  nsnally 
;i  plaintive  cry  or  moan  is  nttcrcd  with  eacli  pain,  and  llic 
patient's  face  heeoines  congested  owing  to  involnntary  fixation 
of  tiie  respiratory  nmscles. 

Reflex  vomiting  is  of  fre^nent  ocenrrenee  as  dilatation  pro- 
Lfresses. 

Tiie  patient  is  coin|ielled  frcfpicntly  to  evacuate  the  bladder 
and  rectum  on  ueeonnt  of  the  inereased  nervous  irritability  of 
I  lie  organs. 

The  pulse  and  respiration  are  not  markedly  affected,  as  a 
rule,  in  this  stage,  though  in  eases  where  it  is  prolonged  the 
rate  of  both  may  be  considerably  accelerated  ;  and  tiie  tem- 
perature may  rise  to  100°  F.,  or  even  higher. 

Anatomy  of  the  Soft  Parts  at  the  End  of  the  First  Stage. 

'I'lie  external  os  is,  as  a  ride,  dilated  so  as  to  admit  three 
fuigers.  The  cervix  is  completely  taUen  up.  The  whoh;  lower 
segment  of  the  uterus  is  thinned  out  somewhat  from  stret(!h- 
iiig;  while  the  upper  segment  is  slightly  thicker  tiian  before 
the  onset  of  labor. 

The  bladder,  as  a  rule,  is  drawn  upward  with  the  (!ervix,  tiie 
upper  end  being  (iisplaeed  forward  over  tiie  piilies.  Tlie 
upper  end  of  the  vagina  is  somewliat  distended. 


LABOR— SECOND   STAGE. 

Mechanism  of  the  Second  Stage. 

During  this  stage  tlie  foetus  is  expelled  from  the  maternal 
passages. 

Vertex  ])resentations  Ix'ing  considered  in  tliis  work  as  nor- 
mal, and  tiic  left  oecij)ito-a!iterior  ])osition  l)eing  l)y  far  tlie 
most  (!ommon,  tlie  corresjiondlng  mechanism  will  lie  fully 
described  at  this  point;  while  the  mechanism  t)f  the  otlier 
positions  will  be  described  only  in  so  far  as  they  differ  from  it. 

The  mechanism  of  tliis  stajre  is  concerned  ciiieflv  witii  tlie 
movements  wdiich  the  fcetal  head  and  trunk  undergo  in  their 
passage  through  tlie  birth-canal. 


108    77//<;  MJ'X'JIAMSM  JA7>   COVllSE  OF  NORMAL  LAIiOli. 

Till'  most  important  |»art  of  the  mcclianlsm  is  that  rclatiiij^ 
to  till"  hctnl^  on  account  of  its  si/c  and  (ii<'  incomprcssihility 
ol'  its  (liamt'tci's  as  co]nj)arc(l  with  tlic  trnnk. 


The  Head  Movements. 

'rhcs(>  arc  :  descent;  Hex  ion  ;  int<'i'nal  rotation;  extension; 
and  finally,  after  expulsion,  I'csiilutiou  or  exlcrnal  rotation. 

Descent:  HesciMit  of  the  head  Ite^ins,  as  already  nicntione*!, 
with  the  rupture  of  the  membranes,  or  as  sooi'  as  it  (!onies  into 
complete  contact  with  the  lower  uterine  segment,  or  os.  It  is 
(•(iii.scti  hy  the  uterine  contractions  i-cinforced  hy  the  action  of 
the  abdominal  musch's  and  diaphra;j;m,  and  persists  through- 
out this  stage,  r<'.sulting  in  the  other  movements  about  to  be 
describetl. 

Flexion:  Tlie  position  of  the  head  is  naturally  one  of  par- 
tial tiexion,  as  it  lies  in  the  lower  uterine  segment  at  the  <mset 
of  the  second  stage.  As  the  head  descends  this  flexion  in- 
creases as  the  result  of  various  cdiiscs: 

(a)  At  the  beginning  of  this  stage  the  intra-uterine  fluid 
pressure  acts  on  the  wliole  base  of  the  skJl,  and  flexion  re- 
sults from  the  different  angles  at  which  the  anterior  and  ])os- 
teriur  slopes  of  the  vertex  meet  the  resistance  of  the  lower 
uterine  walls.  The  friction  offered  by  the  wall  to  the  anterior 
end  of  the  head  is  greater  and  this  end  is  more  impeded  in  its 
descent,  hence  flexion  is  assisted.  This  is  reinforced  by  the 
action  of  the  eircidar  fibres  of  the  cervix  com[)ressing  the 
head.  The  force  exerted  by  these;  Hbres  not  being  ecpial  and 
oi)))osite,  flexion  of  the  head  is  favored. 

{/))  When  the  waters  drain  away  sufficiently  to  permit  the 
fundus  to  come  into  direct  contact  with  the  fcetus,  then  a 
more  ])()werful  force  is  exerted  to  produce  flexion  of  the 
head.  The  })ropnlsive  force  of  the  uterine  action  trans- 
mitted down  tlie  vertebral  column  of  the  fcetus  acts  on  the 
liead  along  a  line  running  nearei*  the  occi[>ital  than  the  sin- 
cipital pole. 

The  head  is  so  attached  to  the  trnnk  that  its  sincipital  is 
longer  than  its  occipital  pole ;  it  corres})onds  to  a  lever  with 
unequal  arms,    the   occipito-atlantoid  articulation    being    the 


MECHASUiM  OF  THE  SKCOM)  STAdE. 


lUi) 


itivntal  point,  and  the  sin('ij)it:»l  ^Ik'  l(tn<;  arm  of  tlie  lovor. 
lIoiK'cllu'  sincipital  pole  is  nutro  acted  on  by  the  resistance 
otl'ered  to  descent,  \vi:ile  tlie  oc'cipital  pole  receives  tlie 
iiiaxinmn   pressnre   iV(»ni   al»ove  (V\ix-   '"'^J') 

linis    is    flexion    prodnee<l 
;nid  inaintain(!d.  Fiu.  56, 

Tlie  advantage  of  llexion  is 
that  it  brinfj^s  the  smallest,  or 
sMboccipito-l)reti;matic,  circum- 
fcrence  of  the  iiead  into  rehi- 
lidii  with  the  girdle  of  resist- 
ance offered  by  the  pelvis  and 
-oft  })arts.  It  also  resnlts  in 
the  occipnt  n  "cliing  the  pelvi(! 
floor  in  advance  of  any  other 
part  of  the  head,  a  point  of 
very  considerable  im[)ortaiu*e, 
as  will  be  seer   later. 

A\'hen  flexion  is  complete  the 
posterior  fontauelle  is  bronght 
within  easy  reach  of  tin.'  ex- 
amining finger.  At  this  time 
il"  the  sagittal  suture  be  felt,  it 
seems  to  lie  nearer  to  the  jxks- 
tcrior  than  to  the  anterior 
wall  of  the  pelvis,  and  the 
head  seems  to  occupy  a  some- 
what ol)li(pie  position  in  the 
|)elvis  as  regards  the  plane  of 
the  brim,  the  anterior  or  right 
parietal  bone  seeming  to  be  at 
a  lower  level  than  is  the  left 
parietal  bone.  This  led  Naegele 
to  infer  that  the  head  usually 
entered  the  pelvis  with  the  sagittal  suture  nearer  to  the  prom- 
ontory than  to  the  pubes.  This  is  not  a  real  but  an  appar- 
ent obli(piity,  and  is  due  to  the  pelvic  inclination.  The  head 
normally  enters  the  ])elvis  with  its  horizontal  ])laue  in  com- 
plete coincidence  with  the  plane  of  the  brim.  This  condition 
is  known  as  ai/iiclitwii.    The  absence  of  the  proper  relation  of 


Ill\istrntiim  tlic  ditlVrciit  Icnuttis  of 
tlic  triintal  arm,  F  H,  and  tlii'  uccipital 
aim,  15  O,  of  the  lever  jireseiite<l  by  the 
la'tal  head.    (Jewett.) 


110  THE  MECHANISM  AND  COURSE  OF  NORMAL  LABOR. 

these  planes  is  known  as  (i^it/ncliti.sm,  a  condition  which 
nsnally  occurs  wlion  any  (h^fonnity  of  tlic  })elvis  is  present. 
Internal  rotation :  The  lonj^  diameter  of  the  ftjetal  head 
occupies  the  rigiit  obli<|ue  diameter  of  tiie  brim  when  the 
position  is  L.  O.  A.,  but  it  must  emerge  at  the  outlet  with  its 
long  diameter  directed  anteroposteriorly,  because  this  diameter 
of  the  outlet  is  the  greater.     The  movement  by  which  the 

Fig.  57. 


Beginninpr  extension  of  head.    (Farabeuf  and  Varnier.) 


oblique  position  at  the  brim  is  converted  into  an  anteropos- 
terior position  at  the  outlet  is  termed  rotdiion. 

Without  good  flexion  of  the  fa^tal  head  rotation  cjinnot 
occur.  As  a  result  of  flexion  the  occipital  pole  of  the  foetal 
head  occupies  a  lower  plane  in  the  ])elvis  than  does  the  siii- 
cipital  pole.  When  the  o('(!ij)ut  is  directed  forward  the  sin- 
ciput must  move  in  a  contrary  direction — that  is,  backward. 
When  the  head  descends  in  tlie  L,  ().  A.  ])osition,  the  occiput 
must  of  necessity  enter  the  up|y'i'  part  of  t!u-  anterior  groove 
on  the  left  side  of  the  pelvis.  It  will  follow  this  groove  in 
its  descent,  and  will  thus  come  into  contact  with  the  pelvic 


MECIIANIXM  OF  THE  SKCO.U)  STAGE. 


Ill 


floor  well  forward  of  the  transvor.so  lino  of  tlio  pelvis.  As  a 
result  of  this  slightly  forward  direction  of  the  <)eei|)ital  polo 
tlio  sincipital  pole  will  descend  along  the  sacro-iliae  groove  on 
the  riu'ht  side  of  the  pelvis.  A\'h(!n  the  ]H'lvie  floor  is  reac^hed 
ihe  line  of  least  resistance  is  downward  and  forward,  lienee 
whichever  j)art  of  the  ftetal  head  (in  this  case  the  oecipnt) 
(nines  into  relationsliip  with  the  pelvic  Hoor  first,  follows  this 
line  tnid  is  directed  to  the  under  border  of  the  synij)iiysis 
huhis.     In  Iv.  O.  1*.  and  L.  O.  P.  positions  the  occiput  de- 


M.ixinunii  ili>tiiiti(iii  of  ju'lvH'  llnnr.     Ki|u;itnr  (if  head  about  to  jiiiss.    (Farabeiif 

and  \'iinii(.'r.) 

scends  along  one  or  otlier,  as  tlu;  case  may  be,  of  the  posterior 
grooves  of  the  jH'lvis,  and  impinges  on  the  pelvi<'  floor  beliind 
flic  transverse  line  of  the  ])elvic  outlet.  Ivotation  thus  is 
longer,  being  through  thre(!-eighths  of  a  circle  instead  of  one- 
ciglith,  as  in  anterior  positions. 

Thus  the  main  (net or  in  causing  rotation  of  the  head  is  the 
icsistance  ofllered  by  the  pelvic  floor.  By  the  time  the  peri- 
neum is  well  distended  rotation  is  completed  and  a  portion  of 


112  THE  MFCHANISM  AND  COURSE  OF  NORMAL  LABOR. 

the  liairv  soalj)  over  the  occiput  is  in  view  between  the  dis- 
tended labia. 

Extension  :  At  the  moment  when  tlie  next  movement,  exten- 
sion, begins,  the  sagittal  suture  is  directed  anteroposteriorlv 
and  the  sinciput  lies  in  the  hollow  of  the  sacrum.  Descent 
goes  on  in  this  positioa  until  the  occiput  clears  the  lower 
border  of  the  subpubic  ligament,  and  the  neck  is  ])ressed 
firmly  against  the  back  of  the  symphysis. 

The  base  of  the  occiput  then  pivots  on  the  lower  edge  of 
the  symphysis,  and  at  each  pain  the  head  extends,  stretching 

Fig.  59. 


Occiput  rides  u]>  in  front   of  symphysis.    Pelvic  floor  retracts.    (Fnrabeuf  and 

Vnriiier.) 

the  perineum  and  vulvar  ring  as  it  does  so.  Gradually  the 
vertex,  brow,  and  face  successively  glide  from  under  the  peri- 
neum, Avhich  retracts  over  the  chin  and  the  head  is  born 
(Figs.  57-59). 

Restitution  or  external  rotation:  Directly  after  the  head  is 
born  it  resumes  its  usual  relation  to  the  shoulders,  namelv, 
with  its  occi})itoniental  diameter  at  a  right  angle  to  the  bis- 
acromial. 

The  shoulders  enter  the  brim   in  the  opposite  oblique  to 


CLIMCAL   PHENOMESA    OF  THE  SECOyD  STAGE.    113 

the  iioml ;  thus  in  L.  O.  A.  position  tlioy  enter  in  tlie  left 
,,l)li(jiie  diameter,  and  as  tliey  descend  tiie  ri^ht  shoulder 
•uiiios  to  the  front.  Hence  the  head  wiien  it  escapes  from 
he  vulva  turns  so  tiiat  tiie  occiput  points  to  the  left  side  of 
lie  mother,  whicjj  is  the  same  position  it  occupied  at  the 
trim.  This  movement  of  the  head  is  termed  refit  lint  ion,  and 
s  of  interest,   as  it    indicates   usually   its  primary    position 

fur.   GO). 

Fio.  GO. 


I'd'tiil  liead  after  restitution.     Shows  also  caput  succedaneum.     (Ribemont- 

Dessaigues  and  Lepage.) 

Delivery  of  the  Trunk. 

The  anterior  shoulder  is,  as  a  rule,  arrested  at  the  lower 
border  of  the  symphysis,  so  that  the  })(>sterior  passes  over  the 
|KM'inetmi  and  appears  at  the  vulva  first.  After  the  po.sterior 
-houlder  escajies  the  anterior  descends  and  is  delivered.  The 
hips  emerge  with  the  bisiliac  diameter  in  the  anteroposterior 
position. 


Clinical  Phenomena  of  the  Second  Stage. 

At  the   conclusion  of  tlie  first  stage  the  pains  not  infre- 
(|iiently  cease  for  a   time,  and  the  more  or  less   exhausted 

8— Obst. 


11-1  THE  MECHANISM  AND  COURSE  OF  NORMAL  LABOR. 

woman  has  a  few  moments  of  rest  and  possibly  of  sleep. 
Especially  is  this  tlie  case  if  ehlonil  has  been  administered. 

The  ])ains  are  more  severe  during  the  second  stage  and 
last  longer;  but  the  ])atient  becomes  more  ]K)])el'nl  as  a  rule, 
for  she  realizes  tliat  with  each  pain  definite  })rogress  is  being 
made.  \Vlien  the  j)elvic  floor  is  reached  the  perineniii 
begins  to  distend  from  the  pressure  of  the  head,  and  the 
sphincter  ani  relaxes,  so  that  not  infre((uently  a  (piantity  ol' 
faecal  matter  or  mucus  esca})es  from  the  anus. 

At  this  time  the  contractions  of  the  abdominal  muscles  arc 
inxoluntary,  and  the  patient  is  forced  to  strain  down  with 
each  pain,  holding  her  brcjath  as  she  does  so.  As  a  rule,  tiic 
woman  grasps  any  support  near  by  firndy  w'th  her  hands 
and  braces  her  feet,  to  assist  her  expulsive  efforts. 

In  the  intervals  between  the  pains  she  rests  quietly  and 
may  fall  asleep. 

When  the  vulvar  ring  is  being  distended  the  sutl'erintrs  of 
the  woman  may  become  so  intense  as  to  result  ii-  a  condition 
bordering  on  delirium.  At  this  period  tlu;  head  advances 
rapidly  with  each  pain,  coming  plainly  into  view  as  it  <l()es 
so.  In  the  intervals  it  recedes,  tiuis  permitting  the  circula- 
tion of  blood  in  the   perineum   to  be  resumed. 

If  tli's  recession  does  not  take  ])lace,  oedema  of  the  parts 
rapidly       nies  on,  and  may  be  very  marked  in  some  cases. 

Usually  there  is  a  pause  when  the  head  is  born. 

Accompanying  the  delivery  of  the  body  there  is  a  gush  of 
waters  and  l)lood. 

After  the  birth  of  the  child  the  woman  soon  quiets  down, 
no  matter  how  noisy  she  may  have  been  ;  the  freedom  from 
pain  affording  her  great  satisfaction  and  a  keen  sense  of  rest. 
Her  temperature  at  this  time  may  be  slightly  elevated  ; 
especially  if  the  labor  has  been  difiicidt.  The  pulse-rate 
rapidly  subsides  and  in  a  few  moments  resumes  its  normal 

frequency. 

Moulding  of  the  Foetal  Head. 

The  child's  head,  even  in  normal  labor,  untlergoes  considerable 
alteration  in  shape  as  it  is  forced  through  the  maternal  passages. 

The  manner  in  which  the  bones  overlap  has  been  already 
referred  to.  •, 


ANATOMY  OF  THE  ISECOND  STAGE. 


115 


The  degree  of  moulding  doponds  on  tlie  relative  !^i/e  of  the 
head  and  the  pelvis,  and  also  upon  tiie  extent  of  ossitieation 
j)i-t'S('nt. 

The  moulding  of  the  head  is  essential  to  the  mechanism  of 
the  expulsive  stage  in  that  it  leads  to  a<laj)ta<ion  of  the  iiead 
to  the  pelvis;  and  also  because  its  c/onf/afion  fav(»rs  rotation 
li\  increasing  the  dip  of  the  leading  j>ole,  so  tiiat  it  is  more 
(■;i-ily  directed  forward. 

Elongation:  In  L.  C).  A.  and  Ij.  ().  I*.  j)ositions  tiie  clonga- 
ii(»ii  of  tiie  head  is -along  a  line  joining  the  chin  to  the  posterior 
upper  angle  of  tlie  right  ])arietal  hone. 

in  K.  C).  A.  and  Iv.  O.  P.  positions  tiie  elongation  of  the; 
head  is  along  a  line  joining  the  chin  to  tiu;  posterior  upper 
iiiigle  of  tlie  left  })arietal  bone. 

Tiiis  deformity  is  accentuated  by  the  capiif  ,snc(r<l(niinii>. 

Caput  Succedaneum. 

Definition:  The  oaj)ut  succedaneum  is  an  o'dematous  swell- 
ing which  is  developed  on  the  |)resenting  part  in  the  course  of 
hii'th,  usually  after  ruj)tui"e  of  the  membranes.  The  vessels 
of  tlie  presenting  part  become  engorged  during  the  pains,  and 
serous  exudatit)n  takes  place  into  that  [)orti(»n  of  the  fetal 
surface  wliich  escapes  the  pressure  of  the  girdle  of  resistance. 

Its  size  varies  with  the  degree  of  force  producing  it ;  hence 
it  is  large  in  difficult  and  jirolonged  labors.  Its  size  is  an 
indication  of  the  degree  of  obstruction  encountered  by  tiie 
flit  us  in  its  passage  through  the  ju'lvis. 

Its  location  indicates  the  position  in  which  the  head  has 
descended.  In  anterior  positions  it  is  situated  on  the  posterior, 
and  in  the  posterior  positions  on  the  anteri(U'  asjiect  of  the 
siimniit  of  the  head,  in  left  positions  it  is  on  the  rigiit  ;  and 
ill  right  ])ositions  it  is  on  the  left  of  the  median  line. 

riie  exact  position  of  the  caput  may  be  modified  if  the 
iicad  has  been  subjected  to  prolonged  [iressure  at  the  outlet  or 
at  the  vulva. 


Anatomy  of  the  Second  Stage 

When  the  head  is  in  tiie  distended  perineum  the  shoulders 
ii(!  just  within  the  dilated  cervix. 


116  THE  MECHANISM  AND  COURSE  OF  NORMAL  LABOR. 

The  uterus  has  retracted  on  tliat  part  of  the  foetus  remain- 
ing inside  it.  The  differentiation  between  its  upper  and  lower 
segments  has  become  marked  ;  and  if  the  hibor  is  a  difficult 
one,  the  retraction-ring  may  l)e  felt  running  obliquely  across 
the  uterus  a  sho"t  distance  above  the  ])ubes.  The  higher  thi> 
ring  is  felt  the  more  serious  "  ,  the  obstruction  which  has  been 
encountered  by  the  f<etus. 

The  bladder  is  now  wholly  above  the  pubes  and  the  urethrn 
is  greatly  el ci gated  ;  hence  catheterization  is  difficult  and 
urination  impossible,  the  pressure  o^'  the  head  increasing  the 
difficulty. 

The  structures  in  the  sacral  segment  of  the  pelvic  ffoor  have 
been  |)ushed  downward  and  backward  ;  the  contents  of  the 
rectum  are  forced  out  by  the  pressure  of  the  head  ;  and  the 
anus  has  become  widely  distended,  permitting  the  anterior 
wall  of  the  rectum  to  come  into  view.  The  edges  of  the  vulva 
are  forced  apart  and  they  VMxy  be  oedematous. 

LABOR— THIRD    STAGE. 

This  stage  of  labor  is  occupied  with  the  detachment  and 
expulsion  of  the  placenta  and  the  membranes. 

Mechanism  of  the  Third  otage. 

Separation  of  the  Placenta. 

The  placenta  is  separated  by  retraction  and  contraction  oF 
the  uterus. 

Many  theories  have  been  advanced  to  explain  the  method 
of  placental  separation;  and  the  following  description  is  but 
a  summary  of  those  most  generally  accepted. 

As  a  result  of  retraction  of  the  uterus  after  expulsion  of 
the  child  the  placenta  is  compressed  to  about  one-half  its 
original  size  before  detachment  occurs. 

The  method  of  its  detachment  depends  on  its  sik. 

If  the  site  be  confined  to  the  Avail  and  does  not  encroach 
on  the  fundus,  the  separation  probably  begins  at  the  margins 
and  advances  toward  the  centre.  If  the  ])lacental  attachment 
is  to  any  extent  fundal,  the  placenta,  as  the  result  of  uterine 


MECIIAMSM   OF   Till-:   Til  III  I)  STAGE. 


117 


retraction,  becomes  bent  over  at  an  anjjjle,  and  detachment 
w  ill  beiiin  at  its  lower  marjjjin  and  detrnsion  will  occur.  That 
is,  th(>  placenta  will  sli})  down  sideways  as  detachment  ^oes 
on,  bcino-  detached  by  the  expulsive  force  of  the  uterine  con- 
tiactions. 

As  separation  advances  uterine  vessels  are  torn  across  and 
-<iiiie  hcmoirhage  takes  place. 

In  some  cases  this  retroplacental  hemorrhage  plays  an  im- 
jMiitant  rnlc  in  placental  detachment ;  and  in  all  cases  it  renders 
( asicr  the  shrinkage  of  the  placental  site  uwuy  from  the 
placenta. 

Separation  of  the  Membranes. 

As  a  result  of  the  protrusion  of  the  "bag  of  membranes" 
through  the  os,  in  the  first  stage  of  labor,  some  separation  of 
the  membranes  from  the  walls  of  the  lower  uterine  segment 
takes  })lace. 

After  rupture  of  the  membranes  and  escape  of  the  waters 
the  non-elastic  membranes  become  thrown  into  folds  and 
w  rinkles,  and  as  a  result  become  partially  detached  in  some 
|»hu'es.  The  ])lacenta,  in  the  j)rocess  of  expulsion,  strij)s  the 
ineinbranes  completely  off  the  uterine  walls  as  it  descends. 

It  is  important  that  the  amnion  and  the  chorion  remain 
firmly  united:  failure  of  these  structures  to  adhere  to  one 
;m(»ther  results  in  portions  of  the  cliorion  being  left  behind 
ill  the  uterus,  a  condition  it  is  desirable  to  avoid. 

In  cases  where  too  early  ru))ture  of  the  mend)ranes  occurs, 
there  is  no  "  bag  of  waters,"  hence  the  nuHiibranes  adhere  to 
the  uterine  wall  too  closely,  and  no  detachment  of  these  can 
occiu-  until  the  placenta  in  its  expulsion  strips  them  off. 


Expulsion  of  the  Placenta  and  Membranes. 

As  the  result  of  uterine  contractions,  the  placenta  is  ex- 
pelled. 

It  usually  presents  at  the  vulva  by  some  spot  on  its  foetal 
a"i))ect  about  two  inches  from  its  lower  margin.  The  presenta- 
tion of  the  foetal  aspect  is  c(iu,sed  by  the  retroplacental  hemor- 
riiage  leading  to  an  inversion  of  the  ])lacenta,  which  has  to  strip 
irom  the  uterine  wall  a  portion  of  the  membranes  between  its 


118  THE  Ml'X'IIAMSM  A.\JJ   CO V USE  OF  NORMAL  LAJiOl:. 


lower  m:ir<>iii  aiul  tlu'  (>«  ;  lieiioe  this  part  is  <k'hiy('(l  to  a  eeilain 
extent  (Fig.  01  j.     'J'lie  liiglicr  in  tlie  nterns  tiie  jjiaeenta  issilii 

ated  tlie   more  inenihraiie  lias  tc 
^'o-  61.  })o  stripped  ofV  ix'tween  its  lowei 

margin  and  tlieos,  and  tliegi'eatei 
is  the  degree  of  invei'.^^ion,  oi 
folding  over  of  the  ])laeent:i. 
The  placenta  never  |)resents  l)\ 
its  margin  at  the  vnlva  nnless  it- 
lower  edge  was  originally  sitnated 
close  to  the  internal  os. 

'Jlie  membranes  are  dragged  out 
l)y  the  descent  of  the  placenta  ; 
hence  they  are  nsnally  inverted 
and  the  amnion  appears  outer- 
most. 

The  whole  mass  of  placent:i 
and  membranes  is  accompanied 
by  a  variable  amount  of  elot> 
and  fluid  blood,  these  coming 
from  the  j)laeental  site. 

After  expulsion  of  the  after- 
birth the  uterus  is  found  re- 
tracted and  contracted  to  about 
the  size  of  the  fo'tal  head.  Its 
.size  varies  with  the  amount  of  retraction  and  with  the  size 
of  the  child. 

The  position  of  the  fundus  immediately  after  labor  is  about 
half-way  between  the  pubes  an<l  umbilicus.  Later,  when  the 
paralyzed  lower  segment  has  regained  its  tone  by  retraction, 
the  fundus  rises  to  a  position  about  the  level  of  the  um- 
bilicus. 

Labor  is  now  completed,  and  the  puerperal  period  begins. 


Inversion  of  tlic  ovnm  and  exinil- 
si(in  of  thf  ])lii('i'nt!i  as  an  invfrtod 
nnil)n.'lla.    (Scluiltze.) 


Blood  lost  in  labor:  The  average  amount  of  blood  lost 
in  labor  is  about  six  to  ten  ounces.  The  total  quantity 
varies  considerably.  Women  who  menstruate  profusely 
habitually  lose  more  than  those  whose  menstruation  is  usually 
scanty. 


OBSTKTRU '  AS TLSKPSIS.  11!) 

THE  MANAGEMENr  OF  NORMAL  LABOR. 

In  tlio  iiKiiia<i('UU'iit  of  a  case  of  labor  it  is  the  duty  of  the 
physician  to  assist  the  woman  in  tiic  processes  oi"  lai)or  wiicii 
iv(|iiir<'(l,  ill  orvl<'r  tiiat  slic  may  ix-  spared  umicccssai'v  siill'n- 
iiiii'  and  discomfort  ;  and  also  to  [))'ot('ct  licr  from  any  iid'cc- 
tion  which  mijiht  be  iinjuntcd  fiom  withont. 

It  has  already  been  nientioned  that  it  is  desirable  in  every 
r;i-e  to  make  a  preliminary  examination  of  the  |»atient  about 
lour  weeks  before  the  expected  continement.  Ilesides  the  ordi- 
narv  obsteti'ic  examination,  tho  (/ciicrd/ ('ondition  of  the  j)alient 
-liiMiid  be  noted  at  this  time.  Any  irrejiiilarities  shoidd  bo 
corrected,  and  ovorythini;  should  be  arranged  so  that  at  the 
(late  of  the  expected  labor  the  patient's  strength  and  vitality 
-hall  i)e  the  best  possible. 

OBSTETRIC   ANTISEPSIS. 

In  1847  Ignatius  1*.  Senimelwcis,  having  been  deej)ly  im- 
pressed by  the  heavy  mortality  in  the  N'ienna  Maternity,  first 
applied  the  antiseptic  method  to  the  management  of  labor.  liy 
sinij)ly  comjielliiig  students  attending  all  cases  of  labor  to 
cleanse  the  hands  thoroughly  in  chlorine-water,  he  reduced 
the  mortality  in  the  maternity  clinic  IVom  12  per  cent,  to 
under  2  jier  cent,  in  less  than  a  year. 

Since  that  date  the  mortality  from  pnerjieral  seyisis  in  all 
maternity  lio,-i[)itals  has  been  reduced  to  considerably  under  1 
|)er  cent. 

That  th<>  appl'v'ation  of  the  antiseptic  method  to  the  man- 
agement of  prirafc  l<ihnr  cnscs  has  not  been  as  widcsprcatl  is 
evidenced  by  the  fact  that  the  niortality-retnrns,  both  in  IJrit- 
aiii  and  America,  show  there  has  been  but  little  decrease  in 
the  number  of  deaths  due  to  jinerperal  sepsis  in  recent 
years. 

The  great  niuiibers  of  women  mIio  throng  the  gynecologic 
clinics  in  all  parts  of  the  country,  suffering  from  disease  dat- 
ing from  a  previous  confinement,  are  witnesses  to  the  fact 
that  the  a|)plication  of  the  antiseptic  method  to  the  conduct 
of  labor  is  still  far  from  being  as  general  as  it  should  be. 


120  TJIl'J  MANAai'JMENT  OF  NORMAL   LABOR. 

Antiseptic  Agents. 

Soap  and  hot  water  arc  |)r()l)ai)ly  the  most  viiliial)l('  agents. 
Many  who  practise  obstetrics  ncglc(;t  tliesc,  whih'  making 
use  of  some  (tnfisejttir  <lni(/  in  s(>liition,  which  blinds  them  to 
the  fact  that  asepsis  is  more  important  tiian  antisepsis. 

'I'he  j)h'ntifiil  ns(!  of  soaj)  and  hot  water  accompanied  by 
muscle  and  common  sense  would  ij:reatlv  reduce  not  ouK- 
mortalitv,  but  also  morbiditv  in  obstetric  work,  even  if  anti- 
septics  had  never  been  heard  of. 

The  use  of  these  agents  should  always  precede  the  employ- 
ment of  antisej)tics. 

Heat,  eitijer  dry  or  moist,  is  the  most  general  and  available 
germicide. 

All  utensils  employed  about  a  jmerperal  woman  should  ix- 
at  least  scalded  thoroughly  with  liot  water,  and  where  j)ossi- 
ble  should  be  boiled. 

All  dressings  or  material  A\hich  it  is  intended  to  use  as 
vulvar  pads  should  be  boiled  or  steamed  before  labor,  and 
kept  carefully  wiappcd  up  until  used. 

All  instruments  should  be  boiled  for  at  least  five  minutes 
in  a  1  per  cent,  soda  solution,  after  which  they  may  be  placed 
in  sterilized  water. 

All  water  used  in  the  labor-room  should  be  boiled,  and 
then  kcj)t  covered  until  wanted. 

In  fact,  cleanliness  in  all  that  ])ertains  to  the  woman,  not 
oidy  during  labor,  but  for  two  weeks  subseciuently,  is  abso- 
lutely necessary  if  it  is  desired  to  have  fever-free  obstetric 
cases. 

In  all  details  the  method  followed  should  be  as  simple  as 
})ossible. 

Chemical  Antiseptics. 

The  most  useful  chemical  germicides  are  mercuric  chloride ; 
Cfwholic  (icid  ;  and  forma /i)i. 

Creolin,  lysol,  and  permanganate  of  potassium  are  also 
very  commonly  employed  in  obstetric  practice. 

It  should  be  remembered  that  soap  decomposes  mercuric 
chloride  and  permanganate  of  potassium,  rendering  them  inert ; 
that  carbolic  acid  and  permanganate  of  potassium  are  incom- 


THE  OHSTETRIi  IAN. 


121 


|)jitil)l<' ;  tl'Jit  nuTciirii!  clilorido  is  deoonijioscd  in  tlic  jncs- 
ciicc  of  albumin,  f'ormiiiji;  tlicivwltli  an  iiuTt  allxinrmatc  (it" 
iiicn'iiry. 

T/icrcJnrc  wiioii  tlic  /atfcr  is  used  in  a  solution  for  douciiinj;', 
it  .-liould  1)0  conihincd  with  tartaric,  acetic,  <»r  hy(ln»clil(tric 
acid  in  the  proportion  of  live  parts  of  the  acid  to  one  of 
I  he  iMercnrial. 

("onvenienee  and  accuracy  are  secured  hy  nsini::  tablets 
■  niit:iinin<jj  mercuric  chloride  coiid)ined  witii  the  j)i(>pei'  pro- 
|M»rlion  of  the  acid.  Sublimate  solutions  are  used  in  strengths 
,.f  from  1  :  5000  to  1  :  500. 

Formalin  solutions  are  now  re|)lacin<r  sublimate  solutions 
lor  (louchinjji;  purposes,  as  they  are  free  from  the  objections 
conuected  with  till'  use  of  the  latter.  Foi-malin  solutions 
vary  in  strenji:th  from  1  :  2000  (o  1  :  500  as  ordinarily  \\^v{\. 
The  strenj»;th  of  the  usual  commercial  ,/'o/v/((////(  is  A^)  per  cent. 
•  •f  the  piseous  compound  formaldehyde  in  water. 

In  the  application  of  the  antiseptic  method  to  the  conduct 
(if  labor  not  only  are  the  obstdrician  and  the  imrsr  con- 
cerned, but  also  the  patient. 


The  Obstetrician. 

The  obstetrician  should  always  be  careful  to  keeji  his  hands 
not  only  clean,  but  also  in  jj^ood  condition.  He  should  avoid 
a~  I'ar  as  possible  any  work  which  will  render  his  hands  rouuii 
and  iiard.  Care  should  be  taken  to  keej)  the  skin  intact,  lor 
cuts,  scratches,  and  chapping  all  render  the  making-  of  the 
hands  surgically  clean  an  impossibility.  Should  there  be 
any  of  these  conditions  })resent,  it  is  the  duty  of  the  obstet- 
lician  to  wear  aseptic  rubber  gloves  when  conducting  a  case 
of  labor.  Care  should  be  taken  not  to  luuxilc  s<j)tic  vidfcriaf  ; 
if  compelled  to  do  so,  the  hands  should  be  sterilized  rei)eatedly 
subsequently. 

The  nails  should  receive  particular  attention,  T  hey  should 
1k'  cut  short  and  well  filed,  so  that  ragged  edges  may  not  be 
left  to  scratch  or  injure  in  the  slightest  degree  the  maternal 
soft  parts. 

There  are  two  methods  of  sterilizing  the  hands,  both  of 
which  are  probably  equally  efficacious.     These  may  be  desig- 


122  TJff':  MANAdKMEM'  OF  SOIIMAJ.   LMiOlL 

iiatcd  r{;sj)('(!tiv('ly  (1)  tlio  Kuhlhimtc  uulliml ;  (2)  tlic  pcniKin- 
(/(UKitc  inctlnul. 

The  Sublimate  Method. 

{(i)  'I'iic  Iiiiiids  ami   forearms  arc  scrubbed  tlioroii*:;!.'}'   lor 
five  minutes  with  a   iiail-hnisli,  iisino'  water  as  Iiol   as  can  l>c 
home  and  a  <xood   soap;  eitlier  an  etliei'«al  or  aIeoli(»lie  >olii 
tion  of  <z;reen  soap  l)ein;^-  tlie  best    for  (liis  piir|)ose.     Special 
attention   must    l»c  paid   to  tlie   nails  and  snl)nn_L;iial   spaces. 

{!))  After  llioron^Ii  rinsino-  in  plain  sterilized  water,  the 
nails  should  he  cleansed  with  a  nail-cleaner  or  sterilized  m.ini- 
cnnf-stick. 

{(-)  Then  the  hands  and  forearms  are  laved  with  pure  alcohol, 
to  dehydrate  the  skin,  for  at  least  one;  minute. 

{il)  The  next  step  is  to  immerse  tho  parts  in  a  liof  1  :2(KMi 
solution  of  mercuric  chloride  for  iVom  three  to  li\e  minutes. 

The  Permanganate   Method. 

The  hands  and  foi-earms  are  scrubbed  and  cleaned  as  in 
steps  <t  and  h  of  tlu;  precedino'  method. 

(c)  They  ar(!  then  immersed  for  live  minutes  in  a  hot  satu- 
rated solution  of  potassium  permanganate,  vig;orous  friction 
boin^  ai)plied  hy  means  of  a  sterilized  swah,  till  tlu;  skin  is 
stained  a  rich  mahoy-anv-hrown. 

{(I)  Then  they  are  bathed  in  a  hot  saturated  solution  of 
oxalic  acid  till  the  brown  stain  has  been  completely  removed. 
This  may  be  followed  by  rinsinu;  in  plain  sterilized  wai'm 
water  or  a  1  :  1000  sublimate  solution. 

It  is  much  to  be  desired  that  tho  obstetrician  should  follow 
the  operatin<j^  surii:eon's  example  iiot  oidy  in  the  preparation 
of  his  han<ls,  but  in  Avea'^iuii'  a  freshly  laundried,  or,  bettei', 
sterilized,  long  coat-gown  of  linen  or  duck,  when  attending  a 
case  of  labor. 

The  Nurse. 

The  nurse  should  be  no  less  particular  in  her  attention  to 
detail,  in  the  application  of  the  antiseptic  method  to  the  con- 
duct of  labor. 


TUh'  IWriENT. 


12:1 


Tlu'  niirso  slioiiM  niako  iiii  ciitii'c  change  of  clothing,  alter 
lakiii"'  :»  l>atli,  lu'lorc  assimiiiin'  cliarn'c  (if  a  jtaticiit  in  lal)«»r. 
Her  (.•Intliin^  slioiild  !)(•  alisolutcly  clean,  and  .slic  whoiilU  wear 
\va>li-<ln's<es. 

If  slie  lias  recently  hei-n  exposed  to  sepsis,  it  is  li«>r  duty  t(t 
inform  the  physician  of  the  fact  In-foro  taking  charge  of  a 
case  of  labor. 

I)('foro  attending  to  the  vidva  of  the  patient  the  inirse 
>ji(tiild  sterilize  her  hands  ihoronghly,  and  the  process  slionld 
he  repeated  each  time  she  has  occasion  to  cleanse  the  parts. 


The  Patient. 

The  aseptic  preparation  of  the  patient  should  begin  weeks 
before  the  expected  <late  of  labor.  She  shonid  be  infornK.'d 
of  the  importance  of  strict  y>('y'.s;/)ur/  r/<'(niflin,ss.  .Any  (li.scd.scd, 
(•(tiidUioufi  of  the  rectnm,  vulva,  or  bladtler  should  receive 
li'eatment. 

At  the  onset  of  labor  the  ])atient  shoidd  take  a  warm  l)ath 
and  then  j)nt  on  clean  linen.  The  lower  bowel  should  bo 
(■in|»li('d   by  an  enema. 

'file  nurse  should  then  thoroughly  scrub  the  lower  part  of 
the  abdomen  and  thighs  with  green  soap  and  hot  N\ater, 
making  use  of  a  soft  hand-brush,  or  a  jute  swab,  for  this  pur- 
pose. 

The  vuh'dr  Jtair  shouhl  be  cli])ped  if  it  be  too  long. 

Then  these  parts  should  be  washed  with  a  warm  solution 
(1:500)  of  formalin  or  of  (1:2000)  mercuric  chloride. 

After  the  parts  lure  been  dried  ^vith  an  ase|)tic  towel  a 
sterile  vulvar  pad  should  be  applied.  The  pad  should  be  worn 
during  the  Hrsi  and  second  stages  of  labor. 

The  nurmal  vaginal  secretion  of  a  pregnant  woman  has  been 
j)roved  to  be  germicidal  ;  therefore  in  normal  cases  no  ante- 
partum vaginal  injections  shoidd  be  permitted.  X<i*^  oidy  is 
vaginal  irrigation  useless,  but  it  may  cause  actual  liarM;  m  im- 
pairing the  secretive  activity  of  the  vaginal  walls,  thus  inter- 
I'ering  with  nature's  protection  against  sepsis. 


124  THE  MANAGEMENT  OF  NORMAL  LABOR. 

PREPARATIONS  FOR  '  *BOR. 

On  the  Part  of  the  Physician. 

The  physician  slioiild  give  the  |  atioiit  a  li^it  of  those  things 
ho  wisiios  lior  to  ))rovi(lo  and  liavo  ready  for  tlie  labor. 

The  j)atient,  if  a  ])riniipara,  sl'onld  he  warned  of  certain 
(•(»n<litions  which  may  arise  at  the  onset  of  hihor,  sncli  as  })rein- 
atnre  rnj)tnre  of  membranes,  hemorrhage,  etc.,  and  instructed 
to  send  ft)r  the  [)hysieian  early. 

Tlie  call  to  a  case  of  hd)or  shonkl  always  receive  tlie  phy- 
sician's immediate  attention,  such  a  summons  taking  prece- 
(hnce  over  everything. 

Ho  shouhl  go  prov'nicil  iritJi  such  instruments  and  drugs  as 
are  likely  to  Ik;  negded  in  the  conduct  of  ordinary  labor  and 
in  the  more  important  obstetric  enjcrgencies.  These  can  all 
be  carried  in  a  hand-bag. 

The  obstetric  bag  should  contain  the  following  : 

A  pair  of  obstetric  forcej^s. 

Two  pair  of  htemostatic  forceps. 

One  needle-forceps  for  suturing. 

Needles,  curved  and  straight,  of  various  sizes. 

A  pair  of  scissors. 

A  Sims  speculum. 

A  pair  of  long  uterine  dressing-forceps. 

A  double  tenaculum. 

A  pelvimeter,  and  a  measuring-tape. 

A  hypodeiniic  case,  well  equij)ped. 

A  gra^'ity  syringe  for  douching,  etc. 

A  long  uterine  douche  nozzle,  either  of  glass  or  metal. 

Two  soft-rubber  catheters,  Nos.  8  to  1 2. 

Catgut,  silk,  and  silkworm-gut  for  suturing. 

Two  nail-brushes. 

A  small  package  of  sterile  iodoform  gauze. 

A  two-ounce  bottle  of  chloroform. 

A  quarter-pound  tin  of  ether. 

A  two-ounce  bottle  of  syrup  of  chloral. 

Antiseptic  tablets  or  solutions. 

An  apparatus  for  the  subcutaneous  injection  of  sterile  salt 
solution  should  also  be  carried.     This  may  consist  of  a  fair- 


ON  THE  PART  OF  THE  PATIENT.  125 

sized  exploring-necdlc,  attached  to  a  piece  of  soft-rubber 
tubing  one  yard  in  lengtli,  and  a  four-ounce  glass  or  ahi- 
miiiuni  funnel. 

Many  iihvsicians  carry  also  a  freshlv  laundried  linen  coat 
and  duck  apron,  as  well  as  a  ))air  of  rubber  gloves.  These 
latter  may  be  sterilized  and  wrapped  up  in  a  package,  not  to 
he  opened  till  required. 

On  the  Part  of  the  Patient. 

The  labor-room :  Whore  practicable,  a  large,  high,  well- 
\ cntilated  room  should  be  selected  for  the  Ivinir-in  chamber. 
It  should  not  be  exposed  to  contamination  from  defectiye 
uluiubiug.. 

The  room  selected  should  be  thoroughly  t  leaned  a  few  days 
before  the  expected  labor  if  possible,  aiid  all  unnecessary 
hangings  and  furniture  removed,  especially  those  likely  to 
collect  dust.  It  is  well  to  have  two  or  three  small  tables 
;ivailable  for  holding  basins,  instruments,  etc. 

All  linen  and  other  things  provided  f  )r  the  labor  should  be 
kept  under  cover  in  this  room,  so  as  to  be  iunnediately  avail- 
able as  required. 

One  dozen  towels  and  a  half-dozen  freshly  laundried  sheets 
should  be  ready. 

Two  rubber  sheets,  or  sheets  of  some  impervious  material,  to 
I'eacli  across  the  bcnl,  about  foiu'  feet  wide,  should  be  provided. 

The  patient  should  also  make  or  obtain  a  labor-pad,  about 
three  feet  S(iuare  and  about  three  inches  thick,  made  of 
ciieese-cloth  and  filled  with  surgical  cotton  or  other  ab- 
sorbent material. 

Also  two  dozen  vulvar  pads  made  of  the  same  material 
siiould  be  provided.  These  shouhl  be  two  inches  thick,  ibur 
inches  wide,  and  ten  inches  long,  and  have  tail-pieces  fttache*! 
to  eithf  end  to  fasten  them  to  the  binder.  Two  or  three 
linen  or  cotton  binders  shoidd  be  ready  ;  each  should  be  a 
yard  and  a  half  long  and  half  a  yard  wide. 

The  labor-pad,  vulvar  dressings,  and  binders,  as  well  as 
half  a  dozen  towels,  should  be  wrap[)ed  in  four  separate  par- 
cels, steamed  for  half  an  hour,  and  then  put  away  and  not 
ojx.'ued  till  required  for  use. 


126     THE  MANAGEMENT  OE  NORMAL   LABOR. 

The  following  should  also  bo  provided  :  a  bed-pan,  a  bottle 
of  antiseptic  tablets  for  solution,  a  fountain-syringe,  four 
ounces  of  tincture  of  green  soap,  a  half-pound  package  of 
absorbent  cotton,  and  a  one-ounce  bottle  of  vaseline,  as  well 
as  a  skein  of  bobbin. 


On  the  Part  of  the  Nurse. 

The  nurse's  first  duty  is  to  prepare  the  patient  for  labor, 
as  has  already  been  described. 

The  labor-bed  sliould  then  be  made  ready.  Tliis  should 
by  preference  be  a  single  bed,  with  a  stiff  spring  and  a  fairly 
hard  hair-mattress.  Over  this  a  rubber  slieet  should  be 
spread  and  tlien  covered  by  an  ordinary  sheet,  which  should 
be  securely  pinned  at  each  corner  under  the  niattr(!ss.  In 
the  middle  third  of  the  bed  another  rubber  sheet  is  then  laid, 
covered  over  by  a  folded  draw-sheet,  both  being  secur('l\ 
pinned  under  the  mattress  at  each  side  of  the  bed.  On  this 
the  labor-pad  is  placed  when  it  is  required.  The  bed  should 
be  accessible  from  both  sides. 

The  nurse  should  see  that  everything  likely  to  be  needed  in 
the  course  of  labor  has  been  provided  and  is  at  hand  for 
immediate  use. 

The  nurse  should  see  that  plenty  of  hot  water  is  at  hand, 
and  make  ready  two  jugs  of  sterile  water,  covering  the  toj)s 
and  placing  them  where  the  water  will  rapidly  cool. 

A  pair  of  scissors  an-l  the  necessary  ligatures  for  the  cord 
are  to  be  sterilized  and  ])laced  within  reach. 

A  small  bowl  containing  a  solution  of  boric  acid,  and  a  few 
small  cotton  swabs,  shoukl  be  ready  ft)r  washing  out  the  child's 
eyes  and  mouth. 

Wrappings  to  receive  the  child  should  also  be  prepared,  and 
in  winter  kept  warm  till  wanted  for  use. 


Use  of  Anaesthetics  in  Labor. 

Obstetric  anaesthesia  differs  from  surgical  anaesthesia  in  that 
in  the  former  the  object  is  to  blunt  and  not  wholly  to  abolish 
the  sensibilities. 


USE  OF  ANJESTIIKTICS  IN  LABOR.  127 

Tlie  prolonged  and  too  free  use  of  ana\stljetios  during  labor 
i-  ('a])al)le  of  liarni  ;  but  at  the  sinio  time  it  is  tlio  duty  of  the 
jihysician  to  relieve  the  patient  of  needless  sutfering-  and  to 
-pare  her  unnecessary  exhaustion. 

The  rule  should  bo  to  use  an  ana>sthetie  \\hen  the  pains  are 
IK  it  >vell  l)orne  without  it.  The  degree  of  ]>aiu  Avhich  some 
women  can  endure  is  wonderful,  wiule  in  other  cases  the 
limit  of  endurance  is  soon   reached. 

Ana>stiietics  are  usually  indicated  toward  the  end  of  the 
-ccond  stage  of  labor.  At  the  acme  of  expulsion  surgical 
aiuesthesia  should  be  induced,  as  a  rule. 

Chloroform  or  ether  may  be  employed.  Chloroform  is 
nciiei'ally  ])referred,  as  the  necessary  quantity  is  less  bulky, 
,111(1  it  is  pleasanter  to  take.  When  partial  auiesthesia  is  all 
that  is  desired  chloroform  is  the  more  satisfactory  ;  but  in 
cases  requiring  surgical  auicsthesia  for  any  length  of  time  ether 
is  undoubtedly  the  safer  and  the  better. 

Chloroform  is  said  to  weaken,  an<l  ether  rather  to  stinsu- 
la<(>,  .iCrine  contractions.  Kthcr  should  not  be  employed 
when  bronchitis  is  present,  or  when  the  patient  is  the  sub- 
ject of  atheroma. 

In  eclampsia  and  tetanic  contraction  of  the  uterus  chloro- 
form is  to  be  preferred. 

Administration :  In  cases  requiring  only  jHirfiaf  (nia'.slhc.^id 
the  administration  can  be  entrusted  to  the  nurse,  acting  under 
the  physician's  direction.  A  mask  or  folded  towel  is  held 
over  the  patient's  face,  and  at  the  approach  of  each  pain  the 
nurse  is  instructed  to  sprinkle  a  few  drops  upon  it.  It  is 
well  in  all  cases  to  smear  the  ])atient's  face  with  a  light  coat- 
ing of  vaseline,  as  the  anaesthetic  may  occasionally  fdl  on 
-kin  and  cause  considerable  in'itation  subsecpiently  should 
tliis  ])!'ecaution  be  overlooked. 

(are  should  also  be  taken  to  remove  any  false  teeth  before 
coiiunencing  the  a<lministration  of  the  ana\<thetic. 

M'hen  suff/icfd  (OKcsf/icxia  is  r(((piired  for  any  length  of 
tiiiic  its  administration  should  never  be  l,eft  to  the  nurse,  but 
a  physician  should  be  called  for  this  purpose. 


128  THE  MANAGEMEyT  OF  XORMAL  LABOR. 


MANAGEMENT    OF    THE   FIRST    STAGE   OF   LABOR. 

Preliminary  Conduct  of  the  Physician. 

The  physician  is  usually  the  one  person  to  whom  the  woman 
in  labor  looks  for  help  and  encouragement  in  her  hour  of  trial. 

His  duty  is  to  win  the  absolute  cov^'lenee  of  the  patient, 
and  to  inspire  her  with  hopefulness  and  courage  throughout 
the  labor. 

His  bearing  should  be  (juiet  and  confident,  and  his  manner, 
while  firm,  should  be  sym])athetic  and  gentle. 

The  effectiveness  of  a  woman's  labor  depends  very  consider- 
ably on  the  j)reservation  of  her  self-control  and  the  absence  of 
strongly  inhibiting  emotions.  The  physician  cannot  afford  to 
lose  the  intelligent  assistance  of  his  patient.  Nor  is  he  justi- 
fied in  adding  fear  or  despair  to  the  sufferings.  Thus,  what- 
ever he  may  tell  her  relatives,  he  should,  after  his  examination, 
give  his  patient  the  impression  that  all  is  satisfactory. 

The  physician  is  sent  for  at  this  time  because  the  patient 
believes  herself  to  be  in  labor.     In  this  she  may  be  mistaken. 

On  entering  the  lying-in-room  the  physician  should  not  pro- 
ceed at  once  to  examine  the  patient ;  but  should  try  to  set  his 
patient  at  ease  and  permit  her  to  become  accustomed  to  his 
presence. 

In  a  quiet,  conversational  manner,  information  as  to  the 
time  of  onset,  the  frequency,  and  the  duration  of  the  pains 
should  be  obtained. 

The  condition  of  the  patient's  general  health  since  the  last 
visit  of  the  physician  should  be  learned,  etc. 

While  thus  engaged  the  physician  may  watch  for  himself  any 
symptoms  of  labor  which  may  be  manifest,  and  at  the  same 
time  he  should  ob.serve  his  ])atient  carefully  for  any  obvion- 
sign  of  disea.se  as  shown  in  her  face  or  bearing,  and  seek  tn 
estimate  for  him.self  the  character  and  type  of  woman  with 
whom  he  has  to  deal. 

Should  It  be  evident  that  labor  has  commenced  the  nurse 
may  then  be  instructed  to  prepare  the  patient,  if  this  has  not 
been  done  already. 

In  any  case  the  patient  should  have  the  bladder  and  bowel 
evacuated  before  any  physical  examination  is  made. 


MANAGEMENT  OF  THE  FIRST  STAGE  OF  LABOR.   129 

Obstetric  Examination. 

External  Examination. 

Preparation:  The  pationt  sh(Hil<l  he  placed  in  the  dorsal 
position  dose  to  the  edge  of  the  bed  with  her  limbs  extended 
and  lier  head  on  a  low  pillow.  The  clothing  should  be 
anaiiged  so  as  to  expose  the  abdomen  from  the  ensiform  car- 
tiiagc  to  the  pubes.  The  physician,  having  washed  his  hands 
ill  hot  water,  may  then  take  a  position  alongside  the  })atient, 
cither  sitting  or  standing  as  may  be  more  convenient. 

Inspection :  The  j)rominence  and  c<Mitour  of  the  abdomen 
should  first  be  observed.  The  condition  of  the  nmbilicus, 
u  hcther  depressed  or  j)rominent,  the  presence  or  absence  of 
striie,  pigmentation,  or  scars,  and  the  condition  of  the  flanks 
should  all  be  noted.  P^vidence  of  uterine  contraction  and  of 
I'o'tal  movements  should  be  looked  for. 

Percussion :  The  abdomen  should  then  be  percussed.  In 
normal  cases  the  dulnoss  should  be  limitinl  to  central  regions 
of  the  abdomen  extending  from  a  short  distance  above  the 
navel  to  the  pubes,  while  the  flanks  and  epigastric  regions 
should  give  a  clear  note. 

Palpation. 

Before  proceeding  to  the  actual  ])alpation  the  character  and 
t('m])erature  of  the  skin  should  receive  attention.  Then  the 
degree  of  panniculus  adiposus,  and  the  presence  or  absence  of 
<c(loma  in  the  hypogastric  region,  should  be  noted.  The  shape 
of  the  uterus  and  the  height  of  the  fundus  should  then  be 
made  out. 

The  upper  borders  of  the  pelvis  should  then  be  examined  by 
jtlacing  the  tips  of  the  fingers  of  each  hand  on  either  iliac 
crest,  with  the  thumb-])oints  resting  on  the  anterior  superior 
iliac  spines.  The  relationship  of  the  spines  as  regards  the 
crests  should  be  observed,  and  a  rough  estimate  of  the  width 
oi'  this  part  of  the  pelvis  made. 

The  upper  border  of  the  pubes  should  then  be  located,  for 
l)cginners  are  very  apt  to  mistake  the  pubes  for  the  head  when 
endeavoring  to  explore  the  pelvic  excavation  from  above. 
9— Obst. 


130  THE  MANAGEMENT  OF  NORMAL  LABOR. 

The  next  point  is  to  explore  the  excavation  of  the  pcUis  in 
order  to  ascertain  whether  it  is  fnll  or  empty,  and,  if  full,  the 
characteristics  of  that  ])art  of  the  fietns  occnjjyinj:;  it.  Tii 
order  to  do  this  tlie  hands  should  be  jjlaced  over  tiie  lateral 
aspects  of  the  lower  abdomen  with  their  palmar  surface- 
almost  facing  each  other,  the  finger-tips  being  directed  toward 
the  ])atient's  feet  and  resting  about  an  inch  and  a  half  above 
l*ou part's  ligaments. 

The  pativ'ut  is  then  directed  to  breathe  deej)ly,  and  with  eacli 
e.\j)iration  the  finger-tips  are  pressed  down wai'd  and  backward 
into  the  pelvis,  care  being  taken  to  avoid  the  pubes.  In  sen- 
sitive patients  the  pressure  exerted  may  cause  pain  ;  in  such 
cases  this  mano-uvre  can  be  carried  out  by  a  series  of  ballotte- 
nicnt-like  movements,  and  the  information  desired  thus  ob- 
tained with  the  minimum  of  discomfort  to  tlic  patient. 

If  the  excavation  be  occupied,  the  finger-tips  are  (piickly 
arrested  in  their  descent.  The  only  ])art  of  the  fietus  whicli 
sinks  into  the  pelvis  before  or  very  early  in  labor  is  the 
head.  This  may  be  recognized  by  its  hardness  and  by  il-> 
globular  outline,  which  can  be  readily  defined.  The  ])reecli, 
on  the  other  hand,  is  soft  and  bulky,  and  its  outline  very 
difficult  to  define. 

Should  tlie  head  of  the  fcetus  occupy  the  pelvis  in  the  nor- 
mal condition  of  flexion  (Fig.  62),  it  \\'\\\  be  noted  that  one 
hand  is  arrested  above  the  brim,  while  the  other  sinks  to  a 
lower  level  before  meeting  with  resistance. 

The  part  of  the  head  wdiich  is  thus  most  accessible  is  tli(> 
brow.  This  condition  is  most  marked  in  occipito[)osterior 
positions  of  the  head.  Hence  if  this  fact  be  noted  the  posi- 
tion of  the  fcetus  is  pretty  well  indicated. 

If  the  head  be  located  at  the  brim  and  the  excavation 
of  the  pelvis  not  be  accessible,  it  should  be  noted  whether  it 
is  engaged — that  is,  fast  in  the  brim — or  whether  it  is 
movable.  If  the  head  be  found  to  be  freelv  movable,  an 
attempt  should  be  made  to  engage  it  by  })ressing  it  down- 
ward and  backward  in  the  axis  of  the  pelvic  inlet,  and  thus 
to  estimate  the  relative  proportions  of  these  ])arts. 

The  upper  pole  of  the  uterus  is  palpated  by  gras])ing  tin 
fundus  firmly  between  both  hands,  having  the  finger-tips  di- 
rected toward  the  head  of  the  mother.    By  thus  steadying  the 


MANAGEMEXT  OF  THE  FIRST  STAGE  OF  LABOR.   131 

luiidus  between  tlie  hands,  by  flexin^;  tlie  liiio;crs  tlie  ii|»i)er 
I < lit d  pole  can  be  palpate*!  f<»r  the  <listiiigiiisliiiio;  marks  of  tlie 
licnd  or  tlie  breeeh.  When  the  lu(ul  ifi  (if  the  fniuhis  it  ean 
he  readily  felt  and  is  very  susceptible  to  balluttement.     Tiie 

Fig.  G2. 


ralpation  with  head  in  pelvic  cavity  :  flnpers  toward  the  occiput  enter  deeper  than 

those  toward  forehead. 

hrct'ch  is  not  so  movable,  is  much  more  bulky,  and  is  more 
(litlicult  than  the  head  to  define. 

The  f(Etal  back  and  limbs  must  then  bo  located. 

The  back  offers  a  broad  resistiiiir  surface,  wliich  is  somewhat 
convex  from  end  to  end.  In  certain  ]>()sitions  it  is  not  ])(>ssibk' 
to  feel  the  back,  but  in  this  case  th(-  lateral  plane  of  the  fietus 
can  be  felt ;  it  is  narrower  than  tlie  back,  not  convex,  and  the 


132  THE  MANAGEMENT  OF  NORMAL  LABOR. 

shoulder  can  generally  be  located  without  difficulty.  B\ 
making  firm  ])re.ssure  downward  on  the  fundus  with  one  hand, 
the  back,  if  directed  to  the  front,  can  l)e  more  readily  })al|)at('(l 
with  the  other.  This  pressure  in  the  long  axis  of  the  f(etf!> 
increases  the  convexity  of  the  dorsal  plane  and  renders  it  more 
accessible. 

The  limbs  are  felt  as  small  nodules,  knees,  heels,  elbows, 
etc.,  which  slip  about  freely  under  the  touch. 

If  the  small  parts  are  muuerous  and  found  near  the  middle 
line  of  the  abdomen,  a  ])osterior  position  of  the  fcetus  is  indi- 
cated.    Finding  of  the  small  parts  in  one  section  of  the  abdo 
men  confirms  the  location  of  the  dorsum  in  the  opposite  region  ; 
thus  small  parts  to  the  right  indicate  a  left,  and  small  parts  to 
the  left  indicate  a  right  position  of  the  fcetus. 

Auscultation. 

Auscultation  is  best  practised  with  the  binaural  stethoscope. 
It  is  a  mistake  to  press  the  bell  of  the  instrument  firmly  on 
the  abdominal  wall ;  it  should  be  allowed  to  rest  lightly  upon 
the  skin,  being  steadied  by  the  slightest  touch  of  one  finger 
on  the  cross-bar. 

The  first  object  is  to  locate  the  point  at  which  the  fuetjil 
heart  is  heard  with  maximum  intensity. 

The  foetal  heart-sounds  are  transmitted  most  loudly  through 
the  back,  generally  about  the  lower  angle  of  the  left  fii't:il 
scapula. 

In  antrriuv  vertex  presentatiovs  the  heart-sounds  are  hear<l 
best  at  a  ])oint  midway  between  the  umbilicus  and  the  anterior 
superior  spine  of  the  side  to  which  the  fietal  back  is  directed  ; 
while  in  posterior  vertex  presevtations  their  point  of  maximnni 
intensity  is  in  the  corresponding  flank. 

Fig.  63  illustrates  the  points  of  maximum  intensity  of  the 
fcetal  heart-sounds  in  the  various  })ositions  and  presentations. 

The  sounds  produced  by  the  fii'tal  heart  have  been  com- 
pared to  the  muffled  ticking  of  a  watch  under  a  pillow,  tlit? 
rate  being  about  120-160  per  minute. 

It  should  be  remembered  that  in  dorsoposterior  positions,  In 
hydramnios,  and  in  certain  other  conditions  the  heart-sounds 
may  not  be  audible. 


MAyAUEMKNT  OF  Till':  FlllST  tiTAUK  OF  LABOR.    V.V,\ 

'I'lio  loiid  rlivtlimic  s\visliiny;-.si)Mn(l  occMirriiiy;  sviiclironoiislv 
with  tlio  maternal  licart-htiit,  occasionally  heard  low  down  on 
niic  or  other  side  of  the  uterus,  is  termed  the  uterine  bruit. 
This  sound   is  caused  hy  the  rushinjj^  of  blood  through  the 

Fio.  63. 


Illustrating  tho  points  of  maxiimun  iiitonsity  of  fecial  heart-sounds  in  vertex  and 

breech  presentations. 


ciilari^ed  uterine  vessels,  and  is  generally  to  be  heard  loudest 
ill  the  neighb(n-hood  of  the  ))laeenta. 

Rarely  a  high-pitched  hissing  or  blowing  sound,  which  is 
synchronous  with  the  pulsations  of  the  fretal  heart,  may  be 
heard.  This  is  termed  the  funic  souffle,  and  is  caused  by  the 
blood  rushing  through  the  vessels  of  the  cord.  It  i.s,  as  a 
rule,  only  heard  when  the  cord  is  twined  around  the  body  of 
the  foetus. 


\:V{  THE  MANAGEMENT  OF  NORMAL  LABOR. 

Vaginal   Examination. 

'V\  t!  |>liy,si('iiiii  havini;  coinplctcd  tlio  external  cxatuiiiation 
i)i'    tlu!   patient,  sIioiiUl    tlieii    ascertain    the    condition    of   tin 
N'lilva,  the  va<i;ina,  the  cer\ix,  and  the  l)a(r  of  waters. 

While  making  the  vaginal  exaniination  he  shonld  note  \\u 
position  of  the  presenting  part,  and  should  make  a  rough  esti- 
mate of  the  capacity  of  the  pelvis. 

Preparations:  TIk;  patient  is  placed  (►n  her  left  side,  with 
h(»r  hips  brought  well  to  the  edge  of  the  bed  and  her  lower 
limbs  Hexed.  The  clothing  shonld  be  so  arranged  as  not  to 
interfere  with  the  ac(!ess  of  the  examining  hand,  and  a  .sheet 
is  then  draped  over  the  patient.  While  this  is  being  attended 
to,  the  physician  should  cleanse  and  sterilize  his  hands,  ac- 
cording to  the  directions  already  gi\cn. 

The  Examhiafion. 

Everything  b(,'ing  in  readiness,  the  \)hysieian  seats  himsell" 
facing  the  [)atient's  genitalia.  The  nurse  is  then  directed  to 
lift  the  sheet  covering  the  patient,  so  as  to  expose  the  but- 
tocks. 

With  his  left  hand  the  })hysieiau  then  gently  cleanses  the 
vulva  with  a  pledget  of  absorbent  cotton  wet  with  an  anti- 
septic solution. 

Having  moistened  his  right  hand  in  the  same  solution,  he 
then  separates  the  lips  of  the  vulva  by  means  of  the  thumb 
and  middle  finger  of  this  hand,  holding  the  examining  fore- 
finger well  flexed  into  the  palm  so  that  it  will  not  come  into 
accidental  contact  with  any  part  of  the  j)atient. 

Having  thus  e"  sed  the  orifice  of  the  vagina,  he  then  ex- 
tends his  forefii.  ,er,  passing  it  gently  in  in  the  direction  of 
the  hollow  of  the  sacrum. 

Having  already  noted  the  condition  of  the  vulva  and 
vaginal  discharge,  he  now  examines  the  perineum  and  tlu- 
posterior  vaginal  wall.  The  finger  is  then  passed  upward 
following  the  curve  of  the  sacrum,  wdiich  should  be  noted, 
until  it  reaches  the  posterior  vaginal  fornix. 

The  posterior  lip  of  the  cervix  will  now  be  felt,  and  is  to 
be  traced  down  till  the  margin  of  the  external  os  is  reached. 


m.\.\A(h:mj:nt  of  the  first  stage  of  eaiior.  1:5.") 

I  lu;  linger  is  tluMi  swcjit  rotmd  the  (.'Xteriuil  os,  note  hciii^ 
lakcn  of  its  conditicm  and  of  tin.'  ilco-ivc  of  dilutatioii  jtnsi'iit. 

Tiie  bag  of  waters  is  ihcii  felt  if  present;  if  not,  the 
riiiHcr  is  inserted  witliin  the  os  until  the  j)resentin^  j)art  of 
the  lu'tiis  is  readied.  Tiiis  is  tiien  e.\|)h»red  for  landmarks 
and  its  position  in  tiie  pelvis  ascertained. 

On  withdrawing;  tiie  fnit^cr  the  anterior  lip  of  tlie  cervix 
sh(»id<l  1)0  foih)\ved  ;  and  tiie  anterior  vaiiinal  wall  as  well  as 
tiie  posterior  surface  of  the  pubes  should  bo  explored. 

Fio.  64. 


Manual  method  of  measuritiR  the  diagonal  conjugate. 


The  capacity  of  the  pelvis  should  then  l)e  ascertained  by 
s\veej)in^  the  tinc:er  about  in  various  directions.  If  j)ossible, 
an  attempt  may  be  made  to  reach  the  jironiontory  of  the 
sacrum  ;  if  this  can  readily  be  touched,  there  is  some  degree 
of  pelvic  contraction  ])resent. 

The  diagonal  conjugate  should  therefore  be  measured. 

For  this  purpose  the  finger  should  be  withdrawn  and  the 
whole  hand  again  immersed  in  an  antiseptic  solution.  The 
first  and  second  fingers  are  then  inserted  into  the  vagina,  and 
the  tip  of  the  second  finger  placed  in  contact  with  the  most 


\'M  Till':  MANMSEMEy'V  OF  SORMAL  LABOR. 

proiiiincut  point  of  tlu;  pronutiitorv  ;  tlio  radial  cd^c  of  tlio 
Iiaiid  is  (Ik'Ii  raised  until  it  rests  against  the  subpubic  lij;a- 
inent  {V\)^.  01).  Tiiis  j)(»int  of  eoiita'-t  is  tiieii  marked  hy  a 
fin^cr-iiail  of  the  other  hand.  On  withdrawing  the  hands 
the  distance  hetwec!!  the  two  points  of  contact  is  then  meas- 
ured and  the  true  conjugate  estimated  (see  Pelvimetry). 

Succeeding  the  Examination. 

Ilavinj^  now  jj^athered  all  his  facts  the  |)hysician  is  enabled 
to  make  a  diagnosis.  It  is  unwise  to  venture  a  diagnosis  till 
all  the  facts  are  in  hand. 

Predictions  as  to  the  probable  duration  of  the  labor  should 
be  a\'oi<led  ;  but  at  the  same  time  the  j»atient  should  be  given 
all  the  encoin'agcmenl  and  assurance  possible. 

If  the  presentation  \)v  favorable  and  the  part  well  engaged 
in  the  pelvic  brim,  the  patient  may  be  allowed  the  liberty  of 
her  room,  and   indeed  should  l)e  en<'ouraged  to  move  about. 

The  attendance  of  the  physician  during  the  first  stage  of 
labor  is  not  re((uired,  in  the  absence  of  any  eom])lication. 

The  nurse  should  be  instructed  to  give  the  patient  small 
quantities  of  I'kju'kI  iioiiris/niiciit  at  short  intervals.  It  is 
well  to  leave  a  couple  of  15-grain  doses  oi'  chloial  to  be  ad- 
ministered to  the  patient,  with  an  interval  of  twenty  minutes 
between  each,  should  her  suffering  become  acute.  T\\v  nuise 
should  also  bo  instructed  to  /:rrj>  fJic  juifirnf  in  hcd,  and  /o 
si(tiiiii<)>i  tJic  pJii/sicidii  when  the  membranes  ruj)ture  or  on 
the  occurrence  of  bearing-down  pains. 

After  an  interval  of  two  to  four  hours,  should  the  mem- 
branes not  have  ruptured,  a  second  vaginal  examination  may 
be  ma<le  to  ascertain  what  ])rogress  has  been  attained. 

Should  it  be  found  that  the  tenseness  of  the  bag  of  waters 
remains  the  same  during  the  pains  as  in  the  intervals,  or 
should  the  os  be  dilated  so  as  easily  to  admit  three  fingers, 
then  the  membranes  may  be  ruptured. 

This  is  accomplished  by  a  scratching  movement  of  the  fore- 
finger, accompanied  by  pressure.  Should  this  fail,  a  sterilized 
})robe  or  straightened-out  hairpin  may  be  emj)loyed  for  this 
])urpose,  tlu!  greatest  care  being  exercised  not  to  injure  the 
maternal  tissues  nor  the  skin  of  the  presenting  part  of  the 
foetus. 


MASAGEMEST  OF  THE  SECOM)  STAGE  OF  LAllOlL    \:\1 

MANAGEMENT  OF    THE  SECOND  STAGE  OF  LABOR. 

Piiriiifj:  the  second  sta<;e  of  lal)(»r  the  patient  slionhl  h(>  kept 
III  h('(l.  Iler  ordinary  nij^ht-elothin;^  sliouhl  he  tt'rned  up 
;iii<l  pinned  at  the  shoidder,  so  us  to  prevent  its  hcin<;  soiled. 

Position:  The;  patient  may  assume  any  posture  (hiriiij;-  lliis 
>tai'('  in  which  she  can  secure  the  greatest  j.mount  of  comfoiM, 
provided  tiiere  is  no  reason  wliy  slie  shouhl  he  constantly  ivcpt 
ill  one;  |)osition. 

She  shouhl  he  enctoura^ed  to  hring  all  her  expidsive  ell'orts 
into  operation,  and  to  this  end  her  feet  may  he  hraced  aj^ainst 
>oine  oi)ject,  and  she  may  he  allowed  to  assist  herself  hy  either 
piillinij::  upon  the  hands  of  a  hystander  or  on  a  sheet-slin<jf 
t';i->(ene(l  to  the  foot  of  the  hed. 

I n  rapid  cases  these  measures  shoidd  he  avoided,  and  the 
jKitient  instructed  not  to  hear  down,  hut  to  relax  her  muscles 
l)V  sliort,  pantiuij^  hrcathiiifj^  or  hy  cryin<^  out  aloud  duriui;;  the 
ai-me  of  the  uterine  contractions,  in  this  way  too  rapid  dis- 
li'iition  and  rupture  of  the  perineinn  may  ho  avoided.  The 
phvsician  shouhl  l)(>  in  (ionstunt  attendance  duriuii-  this  stai^e. 

'Piiere  is  hut  little  occasion  to  maUe  a  vaginal  examination 
when  the  second  stage  of  lahor  is  eshU)lished.  Should  it  he 
found  that  advance  does  not  occur  in  spites  of  apparently  good 
uterine  action,  then  a  vaginal  examination  should  he  made  to 
('-(ahlish  if  possihie  the  cause  of  delay  ;  hut  frecpient  examina- 
tions should  he  avoided. 

During  the  second  stage  an  anaesthetic  may  be  employe<l  to 
control  and  limit  the  expulsive  efforts  of  the  patient  should 
tliis  he  desired,  as  well  a,  to  relieve  her  suffering.  Xot  iufre- 
(jueiitly  it  is  necessary  to  c  iplov  it  in  the  first  stage  for  the 
hitter  ohject.  It  should  only  i)e  administered  during  the 
|t:iins,  according  to  the  directions  already  given. 

When  the  anus  begins  to  distend  with  each  ])ain,  the  head 
lias  reached  the  pelvic  floor  and  rotation  is  under  way. 

Perineal  stage '.  It  is  now  the  duty  of  the  physician  to 
watch  the  effect  of  each  contraction  of  the  uterus  in  advancing 
the  head. 

As  the  perineum  begins  to  distend  with  each  pain,  not  in- 
frequently a  small  quantity  of  frecal  matter  is  expelled  from 
the  anus.    This  must  be  washed  away,  from  before  backward, 


lo8  THE  MANAdEMENT  OF  NORMAL   LABOR. 

so  as  to  prevent   infection,  w  itli   pledgets  of  absorl)ent  cotton 
soaked  in  an  antisepti<r  solution. 

Laceration  of  tiie  jx^rinenni  occnrs  in  abont  35  })er  cent,  oi" 
priniipane,  and  in  ahont  iiiilf  that  nninher  of  nniltipar.r. 
Prevention  of  this  accident  depends  on  the  distensihility  oC 
the  pelvic  floor  and  the  stnallness  ot  the  engagiiiij:  circnnifi  r- 
ence  of  the  fo'tal  head.  Slow  delivci-v  of  the  fcctal  head,  hv 
gradnal  stretching  of  the  perinenin,  niinimi/es  the  ))ossil)ilit\ 
of  rnptnre.  Half  the  injuries  ocenrring  to  the  pelvic  floor  in 
general  obstetric  ])ractice  are  preventable  by  skilfid  manage- 
ment of  the  perineal  stage  of  labor. 

The  patient  shonld  at  this  time  be  placed  on  her  left  side. 
with  her  hips  close  to  the  edge  of  the  bed.  Her  legs  shonld 
be  flexed  and  a  folded  pillow  placed  between  her  knees. 

T'.  physician  shonld  sit  close  to  the  edge  of  the  bed,  facing 
its  foot.  Near  at  hand  on  a  chair  or  low  table  shonld  be  :i 
basin  containing  an  antiseptic  solntion,  in  which  he  may  <lip 
his  hands  from  time  to  time,  as  well  as  ligatnres  for  the  conl, 
scissors,  swabs,  etc.,  which  he  will  reqnire  as  the  case  pro- 
ceeds. 

The  rate  of  the  descent  of  tlie  head  is  moderated  by  con- 
trolling tiie  expulsive  efforts  of  the  patient  and  by  direct  press- 
ure upon  the  perineum.  Should  there  be  evidence  of  <r<l<in<i 
of  this  region,  hot  fomentations  nuiy  be  a})j)lied,  care  being 
taken  first  to  anoint  the  parts  with  carbolized  vaseline,  so  as 
to  prevent  burning. 

\s  the  moment  of  delivery  of  the  head  ap])roaches  the 
physician  should  slij)  his  left  hand  ov(?r  tlu;  patient's  abdo- 
men and  between  her  thighs,  so  as  to  place  his  fingers  on  the 
occiput  as  it  emerges  Ixjlow  the  ))i'!;i<!  arch  (Fig.  <)-")).  I>y 
exerting  ])ressure  with  this  hand  too  early  extension  of  the 
head  can  be  prevented,  and  any  of  tlie  soft  structures  of  the 
pubic  segment  of  the  pelvic  floor,  whi'^^h  may  be  caught  in 
front  of  the  occiput,  can  '  '\  pushed  I)ack  in  the  interval- 
between  the  pains  and  held  out  of  the  road,  so  as  to  j)ermit 
its  early  escape  under  the  arch  of  the  j^ubes. 

The  fingers  of  the  right  hand  are  held  on  the  1ow(M'  side  ol" 
the  vulva,  and  the  thumb  on  the  upper,  while  the  palm  covers 
the  perineum. 

As  the  occiput   escapes  under  the  pubic  arch  pressure  is 


.VAXAdl^MI^yT  OF  THE  SECOND  STAGE  OF  LABOR.    139 

iiKulo  witli  tlio  fiiii^crs  and  thumb  of  the  right  hand,  so  as  to 
l»iisli  the  liead  lorward,  and  at  the  same  moment  tlie  left  liand 
lii-mly  iii;ras|)s  it  in  order  to  moderate  the  rapidity  of  its  eseaj)e  ; 
I  hen  tiie  right  iiand  is  free  to  prevent  the  perineum  slipping 
too  raj)idly  over  the  face. 

As  the  head  escr^pes  from  the  vulva  it  is  well  to  have  the  nurse 
extend  the  lind)s  of  the  patient  somewhat,  which  movement 
results    in  a  certain  degree  of  relaxation  of  the  perineum. 

Fig.  65. 


Protection  of  pelvic  floor  and  delay  of  fietal  head.    (Davis.) 


With  the  hands  placed  as  directed  above  to  control  the  di- 
livery  of  the  head,  this  exten.-;ion  of  the  limbs  interferes  in  no 
way  with  the  physician's  work. 

l)uring  the  moment  of  delivery  the  anjesthetic  should  l)i> 
j)ushed  so  as  to  induce  surgical  auicsthesia,  in  order  to  prevent 
any  unexpected  movement  of  the  mother  and  also  to  spare  her 
agonizing  ])ain. 

Having  delivered  the  head,  the  physician  may  now  quickly 
cleanse  his  hands  in  the  antiseptic  solution  before  proceeding  to 


140     THE  MANAGEMENT  OF  NORMAL  LABOR. 

examine  tlie  neck  of  the  child  to  see  if  it  be  encircled  by  the 
cord. 

Slioiild  this  he  the  case,  lie  may  drawdown  tlie  cord  and  loosen 
tlie  loop  sutHciently  eitlior  to  ])ass  it  over  tlie  child's  head  or 
to  deliver  tlie  shoulders  througii  it  ;  if  this  be  impossible,  it 
must  be  tied,  cut,  and  the  chihl  rapidly  delivered. 

No  effort  for  a  couple  of  minutes  should  be  made  to  deliver 
the  shoulders  after  the  head  has  been  born,  except  when  tlie 
labor  has  been  lon«r  and  dillicult.  Should  they  not  advance, 
then  the  anterior  shoulder  should  be  rea(;hed  if  possible  by 
passing  two  fingers  over  the  dorsal  surface  till  the  arm  is 
reached,  when  it  is  delivered  by  flexing  the  fingers,  so  that  it 
moves  over  the  chest. 

The  physician  should  then  j)lace  his  left  hand  over  the 
fundus  of  the  uterus,  making  firm  j)ressure  upon  it,  while  at 
the  same  time  with  his  right  he  ])ushes  the  head  and  body  of 
the  child  forward  toward  the  pubes  as  it  escapes  from  the 
vulva. 

Immediate  care  of  the  child:  The  nurse  should  then  take 
charge  of  the  fundus,  while  the  physician  atten<ls  to  deariiKj 
the  iiiaeiis  from  tlu;  child's  mouth  and  to  wlpiiif/  its  ci/c.^. 
Efforts  should  then  be  made  to  rsfdh/is/i  rc^jnrntion,  should 
the  child  not  (ny,  by  slapping  it  briskly  or  by  sprinkling  it 
with  cold  water.  When  once  it  cries  lustily  it  should  be  laid 
(HI  its  side,  while  the  mother  is  being  turned  over  into  the 
dorsal  position. 

The  cord  may  now  be  tied  an  inch  from  the  navel.  A  short 
distance  beyond  this  a  second  ligature  is  placed,  and  the  cord 
slijjped  betwee  1  i\u\  middle  and  third  fingers  of  the  left  hand, 
which  is  phu^ed  with  its  dorsum  resting  on  the  child's  abdo- 
men. The  ligatured  ])art  of  the  cord  thus  lies  in  the  palm 
of  the  hand,  so  that  in  cutting  it  there  is  not  the  slightest 
danger  of  the  child's  being  injured  by  the  points  of  the 
scissors. 

The  fiftal  end  of  the  cord  should  then  be  washed  and 
examined  to  see  that  it  has  been  firmly  tied,  M'hen  it  may  be 
wraj)ped  in  a  dry  ])iece  of  sterile  gauze. 

The  child  is  then  wrapped  up  warmly  and  put  in  a  safe 
place  till  it  can  be  washed. 


MANAGEMENT  OF  THE  THJllD  STAGE  OF  LABOR   l4l 

MANAGEMENT    OF   THE    THIRD    STAGE   OF   LABOR. 

Tn  order  to  insure  firm  and  continuous  uterine  contraction, 
cither  the  nurse  or  the  physieian  shonM  take  charge  of  the 
tniuhis  from  the  moment  the  heatl  is  delivered  till  the  binder 
lias  been  applied.  Should  the  uterus  become  relaxed  a  few 
circular  movements  of  the  hand  over  the  fundus  will  stimu- 
late contraction  and  prevent  hemorrhage. 

A  sterilized  bed-pan  or  soup  plate  may  now  be  placed  under 
the  buttocks  so  as  to  catch  any  blood  that  may  escape  from  the 
vaciiia  and  also  to  receive  the  after-birth. 

Lacerations:  While  waiting  for  the  placenta  to  be  delivered 
many  physicians  ])lace  the  nurse  in  charge  of  the  fundus  while 
they  utilize  this  time  to  examine  the  vulva  and  perineum  for 
the  presence  of  lacerations. 

Should  the  lacerations  not  be  extensive,  they  may  be  im- 
iiietliately  sutured  according  to  the  directions  given  in  the 
Treatment  of  Lace  rati  on. "i.  The  sutures  should  not  be  tied 
until  the  })lacenta  has  been  expelled  ;  but  their  ends  may  be 
caught  in  a  pair  of  artery-forceps  meanwhile.  The  advan- 
tage of  passing  the  sutures  at  this  time  is  that  the  patient  is 
still  partially  under  the  influence  of  the  anaesthetic,  and  the 
operation  causes  no  pain. 

Should  the  placoita  not  have  been  expeUed  in  half  an  hour 
after  the  birth  of  the  child,  preparations  should  be  made  to 
deliver  it  by  Credo's  method  of  expression. 

The  patient's  limbs  are  drawn  up  till  her  feet  rest  on  the 
bed  as  close  as  possible  to  the  buttocks,  her  knees  being  widely 
separated.  The  sheet  covering  her  is  then  arranged  so  as  to 
expose  only  the  vulva.  The  physician  should  then  sterilize 
his  hands,  for  in  cases  where  the  placenta  is  foun<l  firndy 
attached  to  the  uterine  wall,  in  whole  or  in  part,  it  is 
desirable  that  the  hand  be  ready  for  immediate  entrance  into 
the  uterus. 

With  his  left  hand  placed  upon  the  fundus  so  that  the 
lingers  are  behind  and  the  thumb  in  front  of  it,  and  tlu;  thumb 
and  Ibrelinger  of  the  right  hand  grasj)ing  the  cord  just  within 
the  vulva,  the  physician,  after  kneading  the  uterus  to  secure 
good,  firm  contraction,  makes  strong,  steady  pressure  down- 
ward in  the  axis  of  the  pelvic  inlet,  at  the  same  time  squeez- 


142  THE  MANAGEMENT  OF  NORMAL   LABOR. 

ing  the  organ  firmly.  AMion  the  plaoentu  is  felt  to  detach  itself, 
gentle  traction  may  be  made  upon  the  cord  so  as  to  guide  it 
out  of  the  vagina. 

Should  the  first  attempt  fail,  it  is  repeated  with  each  succes- 
sive contraction  until  the  after-hirth  is  expelled. 

Should  the  membranes  be  caught,  they  may  be  grasped  by 
the  fingers  of  the  right  hand  and  gentle  traction  made  upward 
toward  the  pubes  and  ])arallel  with  the  vulva,  in  order  to 
sej)arate  them. 

The  nurse  is  now  given  charge  "f  the  fundus  while  the 
physician  carefully  examines  the  placenta  and  membranes  in  a 
good  light  in  order  to  assure  himself  that  no  fragment  has 
been  left  behind.  Having  satisfied  himself  on  this  j)oint,  he 
may  now  take  charge  of  the  fundus  while  the  nurse  j)ro- 
ceeds  to  wash  the  vulva  and  remove  all  soiled  linen  from  the 
bed. 

Retraction  of  the  uterus :  Should  the  fundus  not  retract 
firmly  after  delivery  of  the  ])lacenta,  a  drachm  dose  of  the 
fluid  extract  of  ergot  should  be  administered  to  the  })atient. 
In  all  cases  the  fundus  should  be  gently  kneaded  for  half  an 
hour  after  the  delivery  of  the  placenta,  ^^'hen  retraction  is 
complete  the  abdominal  binder  may  be  put  on,  a  fresh  pad 
applied  to  the  vulva,  and  the  patient  made  comfortable. 

The  physician,  before  proceeding  to  wash  up  and  collect  his 
instruments,  etc.,  should  carefully  examine  the  infant  for  the 
possible  existence  of  developmental  anomalies,  and  to  ascer- 
tain that  no  injuries  have  been  received  in  the  course  of  de- 
livery. 

For  further  directions  as  to  the  care  of  the  newborn  the 
reader  is  referred  to  the  compend  of  this  Series  on  Children'' s 
Diseases. 

Final  measures :  Before  leaving  the  patient  the  physician 
should  assure  himself  as  to  the  condition  of  the  fundus,  the 
lochia,  and  the  })ulse.  The  nurse  should  be  given  full  instruc- 
tions with  reference  to  the  care  of  the  mother  and  the  child. 
It  is  well  to  leave  the  nurse  one  or  two  half-drachm  doses  of 
ergot  to  be  administered  should  the  fundus  show  any  tendency 
to  relax  ;  she  may  also  l)e  left  a  })rescription  for  relieving  the 
after-pains  should  they  prevent  the  patient  resting. 


THE  PUERrERAL  STATE— THE   UTERUS.  143 

THE  PUERPERAL  STATE. 

The  puerperal  period,  or  puerperium,  begins  at  tlie  termination 
of  hihor  ;  and  concludes  when  involution  and  regeneration  of 
the  genital  organs  are  completed. 

This  period  varies  in  individual  cases,  but  averages  about 
six  weeks. 

The  physiological  phenomena  of  the  ])urrperinm  are  :  the 
involution  of  the  uterus  and  vagina;  disintegrati<m  of  the 
(h'ciduaand  the  regeneration  of  the  endometrium  ;  retrograde 
changes  in  the  uterine  ligaments,  pelvic  peritoneum,  cellular 
tissue,  lyniphati(!s,  bloodvessels,  and  nerves  ;  alterations  in  the 
Mood  and  circulatory  systetn  ;  changes  in  body-weight,  tem- 
perature, and  skin,  as  well  as  in  the  urinary  and  alimentary 
s\ stems;  and  finally  the  establishment  of  lactation. 

The  two  opposed  processes  of  decay  and  regeneration  occur 
simultaneously  with  great  rapidity  in  the  puerperium.  These 
|)ro('ess(!S,  which  involve  whole  systems  and  organs,  take  place 
ill  the  natural  healthy  woman  without  artecting  her  subjective 
eoiulition. 

The  puerperal  state,  though  it  is  ]>hysiological,  borders  so 
closely  on  the  pathological  that  conditions  of  disease  may  very 
readily  arise. 

rience  during  this  period  the  woman  is  so  beset  with  diffi- 
euhies  and  dangers  that  accidents  and  comj)licjitions  are 
likely  to  occur  unless  she  is  guarded  and  cared  for  with 
knowledge  and  skill. 

Anatomy  of  the  Parts  Immediately  After  Labor. 

The  Uterus. 

Position:  This  organ  lies  in  an  anteverted  and  anteflexed 
state  with  its  fundus  in  contnct  with  the  anterior  abdominal 
wall.     Its  shape  is  usually  an  irregular  ovoid. 

The  upper  uterine  segment  is  thick-walled  (1|  inches,  .">  to  4 
em.),  and  is  pale  pink  in  color  (m  section. 

i'he  lower  uterine  segment  is  separated  from  the  upper  by  a 
well-marked  line.  Its  walls  being  much  thinner,  are  thrown 
into  folds  by  the  weight  of  the  upper  segment. 


»•». 


144  THE  pvebpehal  state. 

The  cervix  can  roughly  be  made  out,  its  walls  bein^^ 
rather  thicker  than  the  lower  i^egnient.  The  lips  are  usually 
everted,  resting  on  the  posterior  vaginal  wall,  and  are  flattened 
bv  the  weiijht  of  tiie  uterus. 

The  lower  segment  and  cervix  are  much  congested,  and 
thus  contrast  with  the  bloodless  body  of  the  uterus. 

The  placental  site,  which  measures  roughly  4  by  3  inches, 
has  a  ragged  surface,  and  is  somewhat  elevated.  It  shows  tli( 
openings  of  the  sinuses  tilled  with  clots.  The  area  of  the  at- 
tachment of  the  membranes  is  paler  in  color  and  smoother  tlitin 
the  placental  site.  Shreds  ofdecidua  are  scattered  over  the 
surface. 

The  oaTity  of  the  uterus  measures  6  to  6^  inches  (15  to  ll! 
cm.)  in  length. 

The  Vagina. 

It  retains  its  usual  shape,  but  is  much  distended.  Its  walls 
are  thickened  and  their  surface  smooth  and  (edematous ;  they 
also  present  more  or  leso  evidence  of  contusion  or  abrasion. 

The  Vulva. 

The  vaginal  orifice  is  stretched  and  torn  to  a  variable  degree. 
All  the  external  parts  are  frequently  somewhat  bruised  and 
lacerated,  and  may  also  present  more  or  less  cedema. 

The  pelvic  floor  is  greatly  relaxed  and  not  infrequently  torn, 
the  edges  of  the  wound  in  this  case  gaping  somewhat. 

The  Bladder. 

This  lies  in  its  usual  position,  and  is  once  more  a  pelvic 
organ. 

The  Peritoneum  and  Broad  Ligaments. 

The  peritoneum  over  the  body  of  the  uterus  is  smooth  ;  but 
at  the  fiides  and  at  Douglas's  pouch  it  is  thrown  into  folds.  The 
broad  Ugamcnts  lie  folded  and  to  a  certain  extent  compressctl 
between  the  body  of  the  uterus  and  the  pelvic  walls.  This 
compression  of  the  broad  ligaments  must  retard  tlie  circula- 
tion in  the  vessels  contained  in  them,  and  so  lessen  the  en- 
gorgement of  the  uterus. 


INVOLUTION.  145 

The  abdominal  walls  are  relaxed  and  the  skin  usually 
thrown  into  folds  and  wrinkles. 

Physiology  of  the  Puerperal  Period 

Involution. 

The  uterus  :  Imniodiately  after  the  expulsion  of  the  placenta 
the  fun(his  of  the  uterus  may  be  felt  about  half-way  between 
(he  umbilicus  and  the  pubes ;  but  in  a  short  time,  from  one  to 
-ix  liours,  it  will  be  found  to  occupy  a  position  at  or  slightly 
;ilM)ve  the  umbilicus.  The  dilatation  of  the  lower  uterine  seg- 
nuMit  and  cervix  necessary  to  permit  the  passage  of  the  child 
results  in  more  or  less  com})lete  loss  of  tone,  so  that  the  weight 
of  the  upper  segment  compresses  them  ;  but  as  tone  is  re- 
trained they  become  capable  of  sup])orting  the  superimposed 
ueiglit  and  the  fundus  becomes  elevated  slightly. 

From  this  time  the  uterus  diminishes  rapidly  in  size,  so  that 
the  fundus  gradually  sinks,  and  at  the  tenth  day  may  be  found 
at  the  level  of  the  pelvic  brim. 

Involution  of  the  uterus  ])roceeds  most  rapidly  between  the 
third  and  the  twelfth  day  of  the  puerperal  period.  The  uterus 
never  quite  returns  to  its  virginal  condition,  its  cavity  in  the 
parous  woman  being  about  half  an  inch  longer  than  in  the 
virgin. 

Changes  in  the  muscle-cells :  The  firm  contraction  and 
retraction  of  the  uterus,  after  labor,  cut  oil'  its  blood-supjily 
to  a  very  considerable  extent,  and  thus  being  deprived  of 
nourishment  the  muscle-cells  rapidly  undergo  fatty  degenera- 
tion. At  the  same  time  a  porticm  of  the  cell-contents  is  con- 
verted into  a  peptone,  which  is  absorbed  into  the  blood  and 
discharged  through  the  kidneys. 

It  is  doubtful  if  anv  cells  are  destroved  in  toto ;  for 
Sjinger's  observations  prove  that  reduction  of  the  uterus  after 
labor  is  effected  by  a  diminution  in  size  of  the  individual  cells 
and  not  by  their  destruction. 

Changes  in  the  uterine  vessels  and  nerves  :  The  bloodvessels, 
lyinj)hatics,  and  nerves  have  all  participated  in  the  general 
uiowth  during  pregnancy.  These  all  take  on  retrograde 
changes.     The  bloodvessels,  which  are  closed  by  thrombi,  are 

10— Obst. 


146  THE  PUERPERAL  STATE. 

coinprcsst'd,  tliiis  l)riii<::iii(i^  their  walls  in  ajn)().sition.  I'arth 
by  ()r<i:aiiizati()n  of  the  clots  and  j)artly  hy  excessive  growth 
of  e()nne(!tive  tissue  in  the  walls,  the  vessels  become  oh- 
1  iterated. 

Uterine  mucosa:  The  ovum  when  it  is  cast  off  carries  wiili 
it  chieHy  the  upper  layer  of  the  decidua,  which  remain > 
attached  to  tlu;  chorion,  and  leaves  behind  on  the  uterine  wall 
the  lower  cellular  layer  and  the  ^huuhdar  portion. 

Diminished  blood-suj)[)ly  from  uterine  retraction  soon 
results  in  loss  <»f  vitality  in  the  lower  portion  of  the 
decidu.i,  fatty  de'>;eueration  and  disinte^iation  of  the  cell> 
rapidly  ensue,  and  they  are  cast  off  in  the  loch'ud  (Ji.scliaiyi . 
This  pr()ci!ss  soon  lays  bare  the  g;Iandular  layer  from  which 
the  new  niu(!ous  membrane  ori<^inatcs.  The  epithelial  cells  ol' 
the  glaiuhdar  layer  as  well  as  the  interglandular  connective 
tissue  rapidly  proliferate  and  form  the  new  mucous  m<imbranc. 
This  process  takes  about  eight  weeks  to  com[)lete. 

Lochia:  The  term /ocA/Vf  is  applied  to  the  discliarge  whicli 
comes  from  the  vagina  of  tiie  puerjx'ral  woman. 

It  is  composed  of  blood,  degenerated  epithelial  cells,  debri>- 
of  clots,  mucus,  and  quantities  of  harmless  micro-organism-. 
It  begins  after  the  placenta  has  been  delivered,  and  lasts  from 
ten  to  fourteen  days. 

Its  character  changes  as  the  pnerperium  advances.  At  first 
it  mainly  consists  of  pure  blood  mixed  with  cervical  mucus 
and  small  clots — f/ic  /ocliia  nihrd.  In  two  or  three  days  it 
becomes  paler  and  consists  of  serum  and  mucus — tlie  (oc/iln 
serom.  About  the  sixth  day  it  becomes  thicker  and  is  choco- 
late colored  ;  but  as  the  blood  disappears  and  leucocytes  become 
more  abundant,  it  is  white,  having  the  ai)j)earauce  of  thin  pus, 
which  it  practically  is — the  Inch'ui  (ilba. 

Frequently  when  the  patient  first  assumes  the  erect  posture 
the  lochia  again  becomes  tinged  more  or  less  with  blood. 

Its  quantity  was  formerly  greatly  overestimated  by  Gassner, 
who  gave  it  as  about  fifty  ounces.  Recently  Giles,  from  care- 
ful measurement  in  a  large  number  of  cases,  estimated  the 
total  quantity  as  being  only  ten  and  a  half  ounces. 

Its  odor  is  peculiar.  The  lochia  rubra  has  the  odor  of  fresh 
blood;  but  later  the  mucus  from  the  vulvar  glands  gives  it  a 
peculiar  and  somewhat  penetrating  odor.    Practically  the  odor 


CJfANai'JS  IN  THE   URINARY  SYSTEM.  147 

ii:  IV  he  (Ic'fiiK'd  as  an  a('i<l  odor  w  lien  the  discljarp'  is  normal. 
Aiiiinoniacal  or  alkaline  odor  always  sii<;t;('sts  tliat  jmtrcliictivo 
<:(  Tills  liave  piiiR'd  access  to  tlie  vagina. 

Vulva  and  vagina:  Jii  priniipanc  the  liyineu  and  f'oiircliette 
arc  invarial)ly  torn  ;  the  remains  ol"  tlie  former  ju-rsist  aronnd 
llio  va<i:inal  orifice  in  the  form  of  small  irregularly  shaped 
cirvations  which  are  termed  c<iriiiicu/(i'  iiii/rtij'oniics. 

More  extensive  tears  of  the  vnlva  and  ju-rinenni,  if  not 
>iitiircd,  heal  hy  ^rannlation  and  cicatrization,  occasionally 
leavinjz;  extensive  scars. 

The  vagina  rapidly  becomes  smaller  and  narrower;  its  walls 
from  being  smooth,  gradually  boeonie  rngated  though  the 
nigjo  are  never  so  marked  as  in  the  nullipara.  As  the  liyper- 
it'iiiia  of  the  parts  passes  off,  the  vulva  and  vagina  assnme 
more  their  previons  color  and  proportions. 

Involntion  also  takes  place  in  the  uterine  ligaments,  ovaries 
and  tubes,  abdominal  walls,  and  pelvic  joints,  all  gradually 
returning  more  or  less  to  their  condition  as  before  the  occur- 
rence of  pregnancy. 

Changes  in  the  Circulatory  System. 

Pulse :  The  pulse-rate  shortly  after  labor  falls  to  about  00, 
or  even  lower.  The  cause  of  this  lies  in  the  reduction  of  the 
ii'eiieral  blood-pressure  due  to  changes  in  the  constitution  of 
the  blood  and  also  to  the  <lecreased   intra-abdominal   pi'cssure. 

The  blood,  probably  as  t\w.  result  of  hemorrhage  during  and 
after  the  third  stage  of  labor,  becomes  dcHcient  in  red  blood- 
corpuscles  and  liRMUoglobin. 

'Flic  heart,  which  has  become  slightly  hypertrophied  during 
jiregnancy,  quickly  resumes  its  former  cotidition.  jl 

Changes  in  the  Urinary  System. 

The  urine  is  not  markedly  increased  in  quantity.     Peptone  #' 

and  acetone  are  said   to  be   normally  present  in  the  urine  of  ■'. 

puerperal  women.     The  occurrence  of  sugar  is  not  unusual,  '-' 

es|)ecially  when  there  is  distention  of  the  breasts.     Albumin  »; 

may  be  present  for  a  few  days,  but  its  persistence  is  always  of  I 

givive  import.  J 


148  THE  PUERPERAL  STATE. 

The  bladder  not  infrt'(|n('ntly  becomes  overclistcnded  in 
puerpenil  women  and  ruictnrition  impossible.  The  raiiurs 
of  this  (iondition  are  twofold  :  First,  the  bhidder  is  now 
sul)jeeted  to  h-ss  pressure  than  it  was,  beeanse  the  greatb 
(hstended  uterns  lias  been  emptied,  in  eonsecpienee  of  wliicli 
tlie  intra-abd(»minal  |)ressnre  is  gnatiy  decreased  and  tlif 
abdominal  walls  HactMd  ;  hence  the  bladder  lias  more  room 
to  distend  and  less  resistance!  is  offered  to  it.  Second,  small 
lissnres  abont  the  vnlva  smart  severely  when  the  nrine  trickh  - 
over  them,  liencc  the  woman  is  led  almost  unconsciously  to 
retain  her  urine  as  long  as  possible. 

The  Skin. 

During  the  |)uerperium  the  iorad-i/lnmh  become  unusnallv 
active.  '^Phe  skin  is  more  moist  and  not  infreipiently  during 
sleej)  profuse  perspiration  takes  ))lace.  This  is  j)robably  one 
of  the  factors  by  which  the  hydremia  of  pregnancy  is  cor- 
rected. 

The  Digestive  Apparatus. 

Tlie  power  of  digestion  of  solid  food  is  for  a  time  enfeebled. 

Thirst  is  usually  present,  and  is  easily  accounted  for  by  tlic 
great  drain  of  water  from  the  body  by  perspiration,  the  lochia, 
the  milk,  and  the  urinary  secretion. 

The  bowels  are  a})t  to  be  sluggish,  c(mstipation  being  usu- 
ally present,  j)robably  caused  by  the  decrease  in  intra-ai)doni- 
inal  pressure,  the  lax  condition  of  the  abdominal  wall,  and 
the  great  drain  of  water  from  the  system  referred  to  above. 

Loss  in  weight  takes  j)lace  rapidly,  as  elimination  exceeds 
ingestion  during  the  puerperium.  This  loss  is  very  marked 
in  most  cases,  and  has  been  estimated  at  from  one-twelfth  to 
one-eighth  the  body-weight  in  the  first  seven  days.  This 
diminution  should  cease  by  the  tenth  day. 

Lactation. 

By  lactation  is  meant  the  suckling  of  the  infant.  It  usu- 
ally commences  on  the  third  day  and  lasts  for  about  a  year  ; 


LACTATION.  Mi) 

liioiii^li  iifter  tlie  sevonth  or  eighth   iiionlh  there  is  a  (iilliiig 
(.IV  ill   the  <juality  of  milk   set^rctcd. 

The  mammary  glands  an;  two  lar^e  raccmos'.'  glandular 
.iiniiiis  situated  on  the  upper  portion  (►f  the  chest,  anteiior 
to  the  iniiseiilar  structures  of  the  tiior:icic  Mails.  'I'hey 
(iicupy  the  space  bounded  ahove  hy  the  third  rib,  and  below 
l»v  the  sixtli  rib;  on  the  inner  side  by  the  edtre  of  the 
-icrnuni,  and   on  the  outer  bv  the  anterior  axillarv  line. 

They  are  epiblastic  in  origin  and  belong  essentially  to  the 
skin  ;  as  do  the  sweat  and  sel)a(;eous  glands. 

They  are  globular,  and  vary  in  size  in  different  women. 

At  the  summit  of  ea(!h  breast  is  a  small  conical  elevation 
known  as  the  nipple,  which  is  surrounded  by  an  area  of  pig- 
mented skin,  termed  thea/voA/,  in  which  there  is  a  number  of 
large  sebaceous  glands — i\n'.  f/fdntls  of  MonliiaiiHry. 

Internally  each  mammary  gland  is  comjiosed  of  from 
fifteen  to  twenty-four  lobcs^  united  by  a  certain  amount  of 
connective  tissue  and  fat.  Each  lobe  is  divided  into  lohnlvfi, 
and  these  are  further  subdivided  into  a  large  number  of 
mini  or  vesicles,  in  which   tin;  milk   is  secreted. 

The  veddoi  emj)ty  their  contents  into  small  diuits;  these 
excretory  ducts  from  contiguous  lobules  unite  to  form  a 
single  large  /(wfifcroiis  (-(oui/. 

Of  these  latter  there  are  fifteen  or  more  in  ouch  breast, 
( ach  conveying  the  milk  from  a  separate  lobe  to  the  nij)ple. 
The  epithelium  lining  these  canals  is  continuous  with  that  of 
the  integument. 

Colostrum:  Until  the  establishment  of  lactation  the  breasts 
contain  only  "  colostriun,"  which  is  a  yellowish  fluid  resemb- 
ling milk,  but  differing  from  it  chemically,  in  that  it  contains 
more  sugar,  fat,  and  salts.  It  has  a  laxative  effect  on  the 
child,  due  to  the  excess  of  fats  and  salts  it  contains.  Mlcro- 
si'opicalli/  it  can  be  recognized  by  the  large,  so-called  colos- 
tnim-cells,  which  are  simply  large  epithelial  cells  studded 
with  fat-globules. 

Milk  is  the  secretion  of  the  mammary  glands.  It  is  a 
vcllowish-white  fluid  of  an  alkaline  reaction  having  a  specific 
gravity  of  1024  to  1034. 

Good  human  milk  has  approximately  the  following  chemi- 
cal composition  : 


\ 


150  TllE  I'UElil'EliAL  STATE. 

Per  cent. 

Fat,  4.00 

Su^ar,  7.00 

Proteid  (casein),  1.50 

Salts,  0.20 

Water,  87.;JO 

The  fats,  siijjar,  and  proteids  are  produced  from  the  cell- 
lining  the  acini  oi'  the  glands ;  the  plasma  and  salts  are  de- 
rived from  the  blood. 

The  quality  of  the  milk  is  altered  by  varied  conditions  ol' 
the  mother;  mental  and  physical  distnrbances  may  so  change 
the  milk  as  to  render  it  nnwholesome. 

The  quantity  of  milk  secreted  varies  in  different  women  atid 
at  different  times.  At  first  abont  200  c.c.  is  se(!reted  daily, 
bnt  after  the  tenth  day  the  amonnt  increases  to  from  one-half 
'  to  two  litres. 

The  secretion  of  milk  nsually  begins  abont  forty-eight 
hours  after  labor.  The  breasts  distend,  become  engorged  with 
blood,  and  are  painful  or  tender  when  touched. 

When  the  breast  is  fidl  it  is  hard  and  nodular  to  the  feel, 
and  milk  may  be  expressed  from  the  nip])le  on  the  slightest 
pressure. 

The  establishment  of  lactation  may  be  ])ainful,  and  may 
give  rise  to  considerable  emotional  disturbance  on  the  ])ar( 
of  the  patient,  causing  a  slight  elevation  of  temperature;  this 
is,  however,  rare  except  in  primipara\  There  is  no  such 
thing  as  the  so-called  "milk  fever";  if  fever  occur  at  this 
time,  it  is  a  traunfiatic  fever,  and  the  result  of  infection  only 

The  Management  of  the  Fuerperium. 

The  lying-in-room  should  be  in  the  quietest  part  of  the  house 
if  possible.  It  should  be  well  ventilated,  and  the  light  should 
be  so  arranged  as  to  cause  no  inconvenience  to  the  patient. 
It  should  be  kept  thoroughly  clean  and  well  dusted.  The 
temperature  of  the  room  should  be  maintained  at  between  65° 
and  70°  F.  Soiled  linen  should  be  taken  from  the  room  as 
'  soon  as  possible  after  being  removed  from  the  patient.     The 

patient's  linen  and  draw-sheet  should  be  changed  daily. 


('Mil':  or  iiRHASTs,  i\riisix(,\  ktc.  151 

l''ri('ii<ls  and  relatives  should  not  l)e  permitted  to  use  the 
room  as  a  general  nieetinj^-plaee. 

The  care  of  the  genitalia:  Tiie  vidvar  dres>^!ii;is  should  he 
(  haiiired  at  least  every  three  hours  during  the  first  twenty- 
lour;  alter  this  as  ol'teu  as  soiled,  or  three  ov  lour  times 
daily. 

\Vheii  the  pad  is  removed  the  (.'Xternal  genitals  should  he 
cleansed  of  lochia  hy  means  of  swabs  dipped  in  a  saturated 
-ohition  of  horic  acid  and  s(pieeze(l  dry,  hefore  a  fresh  dress- 
iui:'  is  applied. 

Alter  thehed-pan  has  heen  used  the  lips  of  the  vulva  should 
he  o;('ntly  sej)arated  and  a  stream  of  warm  horie-aeid  solution 
poured  over  them  from  a  doueh  ha^  or  small  juti'.  The  parts 
>li()uld  then  he  carefully  drie<l  with  a  sterile  towel  or  hits  of 
i^auze  and  a  fresh  dressing  apj)lie(L 

All  manipulations  should  he  carried  out  with  the  strictest 
ase|»tic  precautions. 

Care  of  Breasts,  Nursing,  Etc. 

The  child  should  he  put  to  the  breast  for  a  few  moments 
every  six  hours  until  the  secretion  of  milU  is  estahlished. 
This  may  he  supplemented  by  an  occasional  ounce  of  sweet- 
ened water  should  the  infant  ])rove  restless. 

When  lactation  is  established  the  child  should  be  suckled 
every  two  hours  from  (>  A.  m.  to  10  \\  M.  Tsuallv  it  is 
necessary  to  fjive  one  nursiuij:  during  the  nijjht  for  the  first  six 
weeks.  The  imj)ortance  of  re^ulai'ity  in  nursinji;  should  bo 
impressed  upon  the  iuother,  for  without  re<:;ularity  it  is  scarcely 
possible  for  mother  or  child  to  do  well.  ( )verfre(pie!it  and 
irrciLcular  nursing-  deran»^es  the  infant's  disxostion  and  imj)airs 
the  (piality  of  the  milk. 

The  nipples  should  be  cleansed  with  a  saturated  boric;- 
aeid  solution,  both  before  and  after  sucklinj;. 

In  (lryin<»;  the  nij)})les  only  absorbent  cotton  or  soft  p;auze 
should  be  employed,  and  care  should  be  taken  not  to  rub 
them. 

Should  they  become  icuilvr  any  antiseptic  emollient  may  be 
aj)plied.  The  followinpi;  makes  a  very  satisfactory  ointment 
for  this  purpose : 


152  THE  PUERPERAL  .'TATE. 

1|.  Acid,  boric,  3J  ; 

Bisniiitli.  subnit., 

Ol.  ricini,  da  .5ss. — M. 

Ft.  uiig. 
Sig.  To  be  applied  after  nursing,  and  covered  with  a  small 
square  of  white  waxed  paper. 

It  may  be  necessary  to  us:'  a  well-fitting  f/lnss  nipple-shield 
for  a  short  time,  should  the  act  of  suckling  give  rise  to  irrita- 
tion of  the  nipples. 

Not  infre(piently,  usually  in  women  with  large,  pendulous 
breasts,  considerable  discomfort,  even  amounting  to  pain,  is 
suffered  when  the  glands  become  distended  with  milk.  In 
these  cases  a  snugly  fitting  hredd-hinder  will  afford  great  ease 
and  comfort.  Either  the  Murphy  or  the  Y  binder  may  be 
employed. 

Contraindications  to  suckling :  While  suckling  benefits  the 
mother  by  promoting  involution  through  refiex  nervous  ac- 
tion, and  while  there  is  certainly  no  food  so  suitable  for  the 
infant  as  mother's  milk,  there  are  still  certain  conditions 
which  may  render  it  unwise  for  the  patient  to  nurse  her  child. 

A  feeble  state  of  health,  tuberculosis,  and  persistent  albu- 
minuria all  contraindicatc  suckling.  The  same  applies  to 
cases  in  which  syphilis  has  been  contracted  late  in  pregnancy, 
for  it  is  possible  the  child  may  have  escaped  infection. 

Inversion  of  the  nipples,  or  severe  and  painful  fissures, 
mastitis,  or  defective  secretion,  all  act  as  contraindications  of 
suckling. 

Nourishment:  As  the  process  of  digestion  is  usually  im 
paired  during  tlu;  first  days  of  the  ])ucrperium,  the  diet  at  thi- 
period  should  consist  chiefly  of  fluids.  Milk,  clear  soup, 
gruel,  cocoa,  week  tea,  toast,  stale  bread,  and  soft-boiled  e^^^i;^ 
may  be  permitted.  After  the  third  day  a  gradual  return  to 
the  usual  diet  may  be  made.  ISIalt  liquors  and  wines  may  be 
permitted  in  small  quantities  if  patients  are  accustomed  to 
their  use. 

Rest:  Everything  about  the  patient  should  be  so  disposed 
that  she  may  obtain  absolute  mental  and  physical  rest.  It  is 
not  necessary,  provided,  uterine  refraction  he  firm,  for  the 
patient  to  remain  constantly  on  her  back  ;  she  may  gently  turn 


,; 


CARE  OF  BREASTS,  NURSINO,  ETC.  153 

over  to  one  or  other  sido  should  she  so  desire.  After  tlit; 
jirst  day  she  may  l)e  allowed  to  rise  almost  to  the  sittiu}^ 
i)(j<tiire  tor  a  short  time,  should  there  Ik;  oceasion,  the  use  ot' 
the  eatheter  thus  being  rendered  unnecessjiry.  All  move- 
iiu'iits  should  be  slow  and  deliberate,  sudden  ehauges  of  posi- 
tion being  always  avoided. 

After-pains:  In  primipane  after-pains  due  to  uterine  eon- 
traetions  are  seldom  severe  enough  to  demand  relief.  In 
imiltipara',  on  the  other  hand,  they  may  be  so  troublesome  as 
to  preelude  all  possibility  of  rest  or  sleep.  Morphine  gives 
it'lief,  but  should  be  used  with  eare.  Doses  of  J— |  gr.  may 
be  repeated  as  often  as  n^quired.  AVhen  it  is  undesirable  to 
use  this  drug,  antifebrin  or  phenaeetin  in  gr.  v  d(>ses,  eom- 
hiiied  with  caffeine  cit.,  gr.  ij,  may  be  given. 

Shoidd  the  uterus  remain  lax  and  soft,  involution  mav  be 
])i(»nioted  by  friction  of  the  fundus  ten  minutes  two  or  three 
times  daily,  and  a  j)ill  containing:  ergot.,  gr.  ij  ;  (piin.  sulph., 
gr.  ij  ;  strych.  sulph.,  gr.  -r^jj  ;  may  be  given  twice  or  thrice  in 
tiie  twenty-four  hours.  After  the  fifth  day  a  hot  vaginal 
(louche,  night  and  morning,  may  prove  of  value  in  this  condi- 
tion. 

Visits  of  the  physician  :  The  first  visit  after  labor  should  be 
made  within  twelve  hours,  and  afterward  one  or  two  visits 
daily,  as  the  case  may  require.  While  the  patient  may  be 
allowed  "out  of  bed  "  when  once  the  uterus  has  become  a 
|)('lvic  organ,  still  she  should  continue  under  the  physician's 
observation  until  fully  convalescent. 

The  nurse  in  charge  of  the  case  should  record,  morning  and 
evening,  the  temperature,  pulse,  and  respiration,  as  well  as 
evacuations  of  the  bowels  and  bladder,  and  the  condition  of 
the  lochia. 

At  each  visit  the  physician  should  note  the  record  of  the 
pidse,  temperature,  respiration,  etc.  He  should  also  exam- 
ine the  condition  of  the  uterus,  the  bladder  (bearing  in 
mind  the  danger  of  distention  of  the  latter),  the  breasts  and 
ni])ples,  the  skin,  the  digestive  a])paratus,  and  the  lochia. 

The  bowel  having  been  pretty  well  cleare<l  at  the  onset  of 
labor,  it  is  seldom  that  a  purgative  is  required  till  the  third 
day.  It  is  usual  to  give  a  dose  of  castor  oil  or  other  laxative 
so  as  to  operate  on  the  morning  of  the  third  day  ;  after  this  a 


154  PATHOLOGY  OF  PREGNAM'V. 

(lailv  movcnK'iit  sliould  bo  obtuined,  and  a  mild  laxative 
should  be  rojriilarly  adininistcrcd  if  rcMjiiirt'd. 

The  infant's  temperature  should  be  taken  twiee  daily  until 
two  days  after  the  separation  of  the  cord,  \vhieh  usually  takes 
place  in  from  Hve  to  ten  days. 

It  should  be  a  routine  practice  to  make  a  bimanual  examina- 
tion of  the  pelvic  organs  in  the  third  or  fourth  week  of  the 
puerperium,  with  th(^  obj(!ct  of  determining  the  ])resence  or 
absence  of  injuries  of  the  vagina  and  cervix,  the  <legree  of 
uterine  involution,  and  the  existence  of  displacement  of  the 
uterus  or  other  abnormal  conditions. 


PATHOLOGY  OF  PREGNANCY. 

THE   DF.CIDUA. 

The  decidual  mucous  membrane  of  the  ])regnant  uterus  may 
be  the  seat  of  disease,  owing  to  the  enormous  hypertro))hy  of 
the  mucous  membrane  incident  to  pregnancy.  These  diseased 
conditions  often  manifest  themselves  in  exaggerated  forms  as 
compared  with  the  non-pregnant  state.  In  consccjuence  of 
the  relation  of  the  decidua  to  the  ovum,  diseased  conditions 
of  this  membrane  may  have  more  sericnis  conse(]uences  thai; 
in  the  non-gravid  state.  Most  decidual  diseases  have  their 
origin  in  either  acute  or  chronic  endometritis. 

Acute  Decidual  Endometritis. 

Etiology :  This  is  a  very  rare  condition.  It  may  result 
from  trauma,  in  consequence  of  attempts  to  procure  al)ortion  ; 
or  from  certain  infectious  diseases.  When  due  to  trauma  the 
inflammation  is  frequently  of  a  sei)tic  nature,  and  is  charac- 
terized by  the  ])resence  of  an  otlensiv(!  ]>nrulent  discharge. 
Deciduitis  accompanying  the  develoj)ment  of  infectious  dis- 
eases during  ])regnancy  usually  results  in  abortion.  This 
I'esult  is  j)rol)ably  due  to  the  hypertrophied  mucosa,  because 
of  its  vascularity,  becoming  the  seat  of  an  intense  inflamma- 
tion and  particij)ating  in  the  eruj)tion  which  usually  afi'ects 
the  mucosa  of  the  body  in  exanthemata. 

The  treatment  in  these  cases  consists  in  controlling  hemor- 


CHRONIC  DECIDUAL   ENDOMETlllTIi^.  155 

rliage,  favoring  abortion,  and  attending  to  complications  jis 
ihey  arise. 

Chronic  Decidual  Endometritis. 

Occurrence  :  Chronic  inflaniniation  of  tlie  decidna  is  very 
Mtiiinion  ;  and  is  tiie  canse  of  a  vast  majority  of  early  alxn*- 
lions.  Usually  the  inflammation  of  the  endometrium  ante- 
dates the  pregnancy. 

Two  forms  are  commonly  observed,  a  chronic  (liff'iD^c  cndo- 
iiirfrili'S,  or  |)olypoid  degeneration  ;  and  a  v<d(U'rh<il  ciulometrtfis, 
or  hvdrorrh  ea  irravidarum. 

In  diffuse  endometritis  there  is  more  or  less  lii/pcrpldfiid  of 
the  connective  tissue,  residting  in  great  thickening  of  the 
(lecidua. 

Should  the  disease  advance  with  (/rcdf  rdjtidifi/  an  abortion 
will  usually  result,  either  from  hemorrhages  into  the  mucous 
membrane,  thus  separating  it  from  the  uterine  wall  ;  or  from 
the  death  of  the  embryo  owing  to  crowding  of  the  ovum  by 
the  rapidly  thickening  decidua.  In  the  latter  case  the  em- 
l)rvo  may  be  absorbed,  and  tlu;  decidua  afterward  cast  off  as 
an  empty  sac  with  greatly  thickened  walls,  forming  what  is 
known  as  a  flc-shi/  mole. 

If  the  inflammation  of  the  decidua  be  of  a  more  rhronle 
t'hdracfer,  the  pregna::cy  may  proc(»ed  to  term.  In  this  case 
tlie  parturition  is  likely  to  be  |)rolonged  by  reason  of  the  un- 
due adhesion  of  the  membranes ;  or  great  difliculty  may  be 
encountered  in  the  third  stage  from  adhesion  of  the  })lacenta 
to  the  uterine  wall. 

fn  the  catarrhal  form  of  chronic  decicbiitis  ti)ere  is  present 
not  only  a  proliferation  of  the  cellidar  elements  of  the  decidua, 
l)iit  also  increased  secretion — /ii/drorrlia'd,  (/rdriddriuii.  In 
this  form  there  takes  place,  every  few  days,  a  discharge  from 
the  uterus  of  a  greater  or  less  (piantity  of  a  clear  viscid 
rK|uid  having  a  yellowish  tinge  and  containing  albumin. 
Hydrorrh(ea  occurs  more  fre(piently  in  multipara^  than  in 
])rimipane.  The  discharges  may  begin  early  in  the  ])regnancy, 
but  usually  occur  towanl  the  end. 

The  treatment  consists  of  keeping  the  patient  as  quiet  as 
possible.  An  anodyne  may  be  administered  should  uterine 
contractions  accompany  the  escape  of  fluid.     Vaginal  douches 


156  PATHOLOGY  OF  PREGNANCY. 

are  likely  to  do  more  liarni  than  good,  and  should  not  he  eni- 
[»loyed. 

Atrophy  of  the  decidua:  Very  often  the  decidua  may  fail 
to  develop  as  it  should  during  pi'egnancy,  tending  to  prolapse 
of  the  ovum,  and  ultimately  to  abortion. 


THE   FCETAL  APFENDAQES. 

The  Amnion. 

The  amnion, like  serous  membranes,  is  liable  to  be  the  site: 
of  changes  of  secretion  ;  and  of  the  formation  of  plastic  exu- 
dates and  bands  of  adhesion. 

Oligohydramnios,  or  Deficiency  of  the  Amniotic  Fluid. 

The  cause  of  this  condition  is  unknown ;  it  is  usually 
associated  with  deformities  of  the  fcetus. 

The  quantity  of  fluid  may  be  so  mucli  below  normal  as 
seriously  to  interfere  with  the  growth  of  the  foetus  and  thus 
to  cause  its  premature  expulsion. 

The  condition  cannot  be  recognized  before  labor  begins. 
Labor  is  apt  to  be  tedious,  owing  to  the  absence  of  the  fluid 
wedge  of  the  "  bag  of  waters.'^ 

Hydramnios,  or  Dropsy  of  the  Amnion. 

Definition :  The  conventional  limit  of  the  quantity  of  liquor 
amnii  is  given  as  from  two  to  four  pints.  Should  this  be  ex- 
ceeded the  condition  of  hydramnios  exists. 

Occurrence :  In  fi'equency  it  is  a  comparatively  rare  con- 
dition, if  the  term  be  restricted  to  cases  in  which  the  quantity 
of  fluid  is  suflficicntly  in  excess  to  cause  symptoms.  It  has 
been  stated  to  occur  in  about  1  in  every  150  to  200  cases;  it 
occurs  more  frequently  in  multigravidse  and  in  twin  preg- 
nancies. 

Etiology :  Until  the  origin  of  the  licpior  amnii  has  been 
satisfactorily  exphnned  the  etiology  of  this  condition  must 
remain  a  purely  hypothetical   problem.     It  may  be  due  to 


HYDRA MNIOS,   OR  DROPSY  OF  THE  AMNION.       157 

Mvorsecretion  or  to  deficient  al)sorj)tion  of  tlie  liquor  aiunii. 
Sonu'  authorities  hold  that  this  fluid  is  derived  from  the 
Idood-eurreiit  of  the  mother  through  the  chorion  and  the 
amnion  by  transudation.  Others  consider  it  is  produced 
>ulelv  1)V  the  fdetus,  either  as  an  excretion  from  the  kidnev 
and  skin  or  by  a  process  peculiar  to  the  amnion. 

Symptoms:  As  a  rule,  hydraninios  does  not  develop  before 
the  fifth  or  sixth  month  of  gestation,  though  it  may  occur  as 
tiirly  as  the  tentii  week.  Usually  the  first  sign  to  attract  the 
patient's  attention  is  the  undue  enlargement  of  the  abdomen, 
which  is  usually  out  of  proportion  to  the  period  of  pregnancy. 
Thus  at  the  sixth  month  the  uterus  may  reach  the  diaphragm. 
Tliis  great  distention  gives  rise  to  oHlenia  of  the  lower  limbs, 
|)alj)itation  of  the  heart,  and  dyspnwa.  Locomotion  becomes 
(lilficult,  the  functions  of  the  liver  or  kidnev  may  be  inter- 
fered  with,  and  icterus  or  albuminuria  develop ;  sleep  may 
also  be  interfered  with,  and  the  patient  becomes  worn  and 
haggard. 

On  palpation  the  uterus  is  tense,  and  the  ftetus,  if  felt,  will 
he  found  preternaturally  mobile ;  while  on  auscultation  the 
heart-sounds  may  be  feeble  or  inaudible. 

Diagnosis :  The  condition  is  to  be  differentiated  from  twin 
})regnancy,  ascites,  and  ovarian  cysts,  as  follows  : 

In  tirin  prcf/nant'i/  the  enlargement  of  the  abdomen  begins 
earlier  and  not  abruptly  at  about  the  sixth  month  ;  the  preter- 
natural mobility  of  the  foetus  is  not  present.  Two  fcetal  heart- 
sounds  in  different  ])arts  of  the  abdomen  may  be  heard.  It 
may  be  possible  to  palj)ato  two  fcrtal  heads  and  bodies. 

In  ascifcs  the  symptoms  of  pregnancy  are  absent,  but  it  is 
(|uite  possible  that  both  conditions  may  be  present  in  the  same 
case.  On  ])ercussion  a  dull  note  is  obtained  in  the  flanks, 
while  the  central  portions  of  the  abdomen  are  tympanitic.  In 
hydraninios  the  dulness  is  in  the  central  region  of  the  abdomen 
whi'o  th  flanks  are  tympanitic.  In  ascites  change  in  the 
patienr  s  position  alters  the  location  of  the  tympanitic  areas. 
In  ascites  organic  disease  of  the  heart,  liver,  or  kidneys  Avill 
be  found  to  exist. 

Ovarian  cyst  is  to  be  distinguished  by  the  history  and  ])hys- 
ieal  signs;  the  growth  is  more  gradual  and  longer  in  develop- 
ment.    Menstruation  is  generally  present.     The  fluid  wave  is 


168  PAT  no  LOGY  OF  PREGNANCY. 

more  pronounced.  Xo  fn'tal  }>art.s  can  he  palpated.  A 
bimanual  examination  will  permit  tiie  uterus  to  he  differen- 
tiated from  the  tumor.  The  enlargement  of  the  abdomen  is 
not,  as  a  rule,  as  symmetrical  as  in  hydramnios. 

Prognosis:  For  the  mother  this  is  usually  favorable,  but 
probably  one-fourth  of  the  children  are  born  dead  or  non- 
viable. The  risk  to  the  mother  is  increased  by  the  tendency 
to  malposition  of  the  (ihild,  by  overdistention  of  the  uterii> 
leading  to  changes  in  its  stnu^ture  which  render  hemorrhages 
during  and  subseciuent  to  labor  more  fre(|uent,  and  by  the 
increased  liabilitv  to  collapse  following  the  sudden  escape  of 
fluid. 

Treatment:  The  abdomen  may  be  su])ported  by  a  properly 
fitting  abdominal  binder  ;  the  patient  should  be  kept  at  rest 
as  much  as  possible.  When  the  distention  becomes  extensive 
and  serious  symi)toms  develop  then  the  membranes  should  be 
ruptured.  When  this  is  done  the  li(pior  amnii  should  be 
allowed  to  escape  slowly  and  i)recautions  should  be  taken  to 
avoid  syncope.  Strychnine  (gr.  y^^)  and  fl.  ext.  of  ergot  (.^ j) 
should  be  administered  after  the  placenta  has  been  delivered,  to 
insure  good  uterine  contraction  and  to  avoid  the  risks  of  post- 
partum hemorrhage. 

Other  Affections  of  the  Amnion. 

Amniotic  bands :  Karly  in  embryonal  life  should  there  not 
be  sufficient  liquor  amnii  ])resent  to  separate  the  amnion 
from  the  early  formed  skin  of  the  embryo,  adhesions  may 
form  between  the  skin  and  the  amnion.  As  the  anniiotic 
cavity  becomes  distended  the  adhesive  material  becomes 
stretched,  finally  forii:ing  bands  of  greater  or  less  length 
and  thickness.  Xo  satisfactory  theory  has  been  advanced  to 
explain  the  pathology  of  this  condition.  Braun  regards  the 
adhesions  as  resulting  from  folds  of  amnion,  inflammation  of 
the  amnion  being  impossible,  as  it  contains  no  bloodvessels. 

The  bands  thus  formed  result  in  producing  grave  defi)rm- 
ities  in  the  fetus,  such  as  eventration,  anenceplialus,  amputa- 
tion of  the  limbs,  etc.  The  foetal  cord  mav  be  artificially 
shortened,  or  even  completely  severed  by  such  amniotic 
bands. 


HYDATIDIFORM  DEGENERATION  OF  CHORION.     159 

Premature  rupture  of  the  amnion :  Sovoral  casos  liavo  beon 
imported  wliorc  later  on  in  piv^nancy  the  amnion  lias  nnder- 
Moiie  rnptnre  and  yet  the  intet2;rity  of  the  ovnm  has  been  pre- 
served by  the  ehorioii.  The  amnion  in  these  eases  is  nsnallv 
toimd  rolled  nj)on  itself  and  forming  a  sort  of  ontf  abont  the 
jilaeental  en<l  of  the  eord. 

Alterations  in  the  character  of  the  liquor  amnii :  Tiie  licpior 
aiiniii  is  a  clear  limpid  Huid  in  the  earlier  montiis  of  gesta- 
tion ;  later  on  it  becomes  thicker  and  contains  small  wiiit'sh 
Ihikes  derived  fnwn  the  vernix  caseosa.  In  cases  of  death  of 
the  fetus  with  maceration,  the  fluid  becomes  much  thickened, 
of  a  dirty  brownish  or  greenish  color,  and  occasionally  emits  a 
I'cetid  odor. 

The  Chorion. 

Hydatidiform  Degeneration  of  the  Chorion,  or  Vesicular  Mole. 

Occurrence:  This  is  the  only  disease  of  this  membrane 
which  is  in  any  degree  common. 

It  is  characterized  by  hypertrophy  of  the  chorionic  villi, 
and  by  their  conversion  into  cysts  varying  in  size  from  that 
ol'  a  millet  seed  to  a  hen's  egg.  These  cysts  are  connected  to 
each  other  and  to  the  base  of  the  chorion  by  ])edicles  of 
various  lengths  and  are  filled  with  a  fluid  much  resembling 
the  li(jUor  amnii  (Fig.  66). 

Pathology :  The  degeneration  of  the  chorion  usually  begins 
not  later  than  the  tenth  week  ;  as  a  rule  the  whole  membrane 
is  involved  and  the  fetus  perishes;  in  fact  it  is  seldom  to  be 
luimd  when  the  mole  is  expelled.  Tlie  epitheliinn  lining  the 
cliorionic  villi  is  the  part  first  affected,  it  undergoes  a  marked 
|)r()liferation  which  distends  each  villus  and  thus  the  grape- 
hke  bodies  are  produced.  Occasionally  when  the  disease 
comes  on  late  it  may  be  limited  to  tiie  placenta.  In  excep- 
tional instances  the  growth  may  encroach  on  the  uterine  wall 
and  even  ])enetrate  the  ))eritoneal  covering. 

Etiology:  Nothing  definite  is  known  as  to  the  cause  of  the 
disease.  It  occurs  most  frequently  between  the  ages  of  twenty- 
live  and  fortv  vears. 

Vesicular  mole — symptoms :  Three  symptoms  are  available 
I'nr  tlie  diagnosis  of  this  condition  : 


160 


PATHOLOdY  OF  PRKG NANCY. 


((()  Tliere  usually  occurs  a  more  or  loss  profuse  sernsan- 
(/niiicotis  <iiHclmr(/e  from  the  uterus  resemhliut^  red  currant- 
juice.     This  discharge  may  he  continuous  or  intermittent. 


Fio.  66. 


Vesicular  mole.    (Modified  from  Ribemont-Dessaigncs  and  Lepage.) 


(6)  A  .sudden  and  rapid  increase  in  the  size  of  the  abdomen, 
in  which  tlie  uterine  enlargement  does  not  correspond  to  tiic 
sup])osed  j)eriod  of  gestation. 

(c)  The  expulsion  of  cysts  from  the  vagina.  This  is  the  only 
pathognomonic  symptom    and  is  comparatively   rare.      The 


ANOMAUiES  Oh'  THE  PLACKNTA.  iGl 

iiUM'iiri  iisiiully  prosonts  a  doiiixliy  feel  and  tietal  movements 
and  hallottement  are  absent.  The  condition  may  be  eont'onnded 
with  placenta  pra-via  and  liydramnios. 

Prognosis:  This  i.s  rarely  <irave  tor  the  mother,  bnt  is  gen- 
.  lallv  fatal  for  the  child.  The  dangers  which  threaten  the 
mother  are  hemorrhage  anil  se{)tic  infection. 

Vesicular  mole — treatment:  The  nterns  shonld  be  emptied 
;i>  sot)n  as  a  diagnosis  is  established.  The  patient  should  be 
aiiit'-theti/.ed,  the  os  dilated,  and  the  growth  slowly  removed, 
I  lie  hand  only  being  used  for  this  purpose.  Should  it  be  im- 
possible completely  to  clear  the  uterus  in  this  way,  then  the 
l)hmt  curette  may  be  emi)loye(l ;  but  it  must  be  borne  in  mind 
that  the  uterine  wall  mav  be  so  thinned  out  in  areas  as  to  be 
vcrv  easily  ))enetrate(l.  This  shoidd  be  followed  by  a  hot 
uterine  doiiclu!  and,  if  uterine  retraction  fails,  the  cavity  of 
the  uterus  may  be  packed  with  iodoform  or  plain  sterilized 
<iaii/e. 

Anomalies  of  the  Placenta. 

( )f  position,  size,  shape,  and  weight :  Xormally  the  position 
of  the  placenta  is  near  the  fundus  uteri,  but  it  may  occupy 
any  position  on  the  uterine  walls  (see  Placenta  Fncvia). 

\n  size  it  may  vary  considerably.  In  conditions  of  chronic; 
iiillnmmation  of  the  endometrium  the  placenta  may  be  ab- 
normally thick  and  enlarged  in  all  directions.  Atrophy  of 
the  decidua  or  interstitial  overgrowth  followed  by  retraction 
may  cause  the  placenta  to  be  abnormally  small.  In  this  case 
the  fietns  will  be  found  ill  developed. 

The  following  varieties  as  to  shape  may  be  encountered  : 

Placenta  membranacea :  The  villi  may  persist  over  the 
entire  surface  of  the  chorion  and   may  all  develo]>  equally. 

Crescentic,  or  horseshoe  placenta:  This  is  a  very  rare  form. 

Battledore  placenta:  In  this  form  the  cord  is  inserted  at 
the  margin  of  the  placenta.  Occasionally  an  accentuation  of 
this  form  is  seen,  in  which  the  vessels  from  the  cord  branch 
out  before  reaching  the  placenta — this  is  termed  a  velainentous 
insertion  of  the  cord. 

Placentae  succenturiatae :  There  may  occasionally  be  found 
two  or  more  distinct  masses  of  placental  tissue  produced  by 
the  growth  of  isolated  patches  of  chorionic  villi.     The  vessels 

11— Obst. 


162  FATIWLoar  OF  PREGNANCr. 

of  each  patch  course  alon^  the  inenihnines  to  unite  with  tljost 
going  to  the  cord.  In  multiple  pregnancies  each  chiUl  may 
have  its  own  placenta. 

Diseases  of  the  Placenta. 

Calcareous  degeneration  of  the  placenta:  Deposits  of  linn 
salts  in  the  placenta  are  not  nncommon.  TJiese  deposits  only 
occur  as  tine  sand-like  ])articles,  or  as  scales.  Tiiey  usnall\ 
occur  at  the  edjjfes,  though  they  may  he  found  in  the  suhstaiKv 
of  the  cotyledons ;  and  consist  of  amorphous  phosphate- 
and  carbonates  of  lime  and  magnesia.  They  cannot  be  saiil 
to  have  any  pathological  significance. 

White  infarctions:  Yellowish  or  grayish  masses  of  degener- 
ated placental  tissue  are  to  be  found  in  nearly  every  pla(;ent;i. 
When  small  and  few  in  number  they  have  no  pathological 
significance ;  but  if  extensive,  fietal  death  may  result. 

Fatty  degeneration  of  the  })la(!enta  may  occur  as  the  rcsiili 
of  some  local  obstruction  of  blood  su])ply  to  the  parts  affected. 
Small  areas  are  commonly  observed  close  to  the  margin  of  tlic 
placenta.  If  extensive  degeneration  occurs  the  function  of 
the  placenta  may  be  interfered  with  and  the  fuetus  perish. 

Placental  Apoplexy. 

Definition :  This  is  an  eifusion  of  blood  either  within  or  l)o- 
hind  the  placenta.  If  it  takes  place  before  the  third  montli 
the  effused  blood  may  force  its  way  between  the  loose  attach- 
ments of  the  decidua  and  chorion  and  thus  result  in  abortioD, 
a  very  common  occurrence. 

Joncquemin  described  three  well-marked  forms  of  placental 
apoplexy  as  follows : 

(a)  The  effusion  takes  place  directly  into  one  or  more 
placental  cotyledons  forming  here  and  there  small  soft  clots. 

(b)  The  effusion  leads  to  destruction  of  portions  of  placenta 
forming  irregular  cavities  which  are  surrounded  by  infiltrated 
and  reddened  areas. 

(c)  The  effusion  may  occupy  a  number  of  clearly  defined 
irregular  cavities  of  varying  sizes,  from  millet  seed  to  a 
pigeon's  egg,  which  are  not  surrounded  by  areas  of  infiltra- 


PLACESTITIS.  IQ'l 

ti(»n.     In  tlino  these  iij)()j)lo(!ti(^  areas  lose  their  color,  become 
denser,  and  form  yellowish-white  masses. 

Causes:  IMacental  ai)()i)l('xv  is  determined  hy  diseased 
states  of  either  the  maternal  or  the  fo'tal  strnetui'es  enterini^ 
into  the  formation  of  the  ])laeenta.  Most  eommonly  the 
e;inse  is  niafcrnal  in  origin,  as  nephritis  and  allmminuria, 
which  prodnee  increased  arterial  tension  and  venons  oon- 
-fc-tion.  Ti-anmatism,  as  a  hlow  or  kick  nj)on  the  abdomen, 
iii;i\'  produce  it. 

Uarcly  tiie  cause  lies  in  diseased  conditions  of  the  ffrtdl 
rill'i  ieadiiii::  to  rupture;  Avhen  the  umbilical  vessels  are  dis- 
eased, rupture  ol'  one  or  nu>re  of  their  branches  may  result 
in  exsauuuination  of  the  f<etus  and  its  dea  h. 

The  results  of  placental  apoplexy-  depend  on  the  stan;e  of 
gestation  at  which  the  hemorrha<;e  occurs,  the  numl)er  of 
clots  fornu'd.  and  the  extent  of  ])lacental  tissue  involved. 
After  th(!  third  month  placental  apoplexy  but  rarely  results 
in  ;il>()r(ion  or  jiremature  labor.  Jf  the  effusion  is  large  and 
the  placenta  situated  low  down,  the  blood  niay  dissect  its 
\\;iv  down  to  the  os  and  escape,  constituting  (uridental  lionov- 
rli<i(/<'.  Larg(!  effusions  may  result  in  destroying  so  much  of 
the  placenta  that  the  nourishment  of  the  fietus  is  impaired 
to  -uch  an  extent  that  it  is  born  feeble  and  puny. 

Placental  apoplexy — symptoms :  Slight  hemorrhage  gives 
rise  to  no  symptoms;  large  hemorrhages  give  rise  to  pain 
and  tenesmus.  If  these  symptoms  are  produced,  then  death 
of  the  fo'tiis  will  probably  follow. 

Treatment  consists  in  absolute  rest  and  sedatives,  such  as 
morphine  (gr,  |),  administered  every  six  hours. 

Placentitis. 

This  term  is  applied  to  an  inflammation  of  the  substance 
(•f  the  placenta.     The  condition  is  rare. 

Pathological  changes:  Some  anthorities  contend  that  by 
icMson  of  the  anatomical  structure  of  the  placenta  a  true  in- 
llanunation  cannot  occnr.  But  it  is  certain  that  a  marked 
h)jit<rpl<(mi  of  the  connective-tissue  cells  entering  into  the 
foiination  of  the  ])lacenta  does  sometimes  occnr.  This  fibrous 
change  may  originate  in  the  decidua  serotina,  the  placental 


164        PATHOLOGY  OF  PREO NANCY. 

villi  or  the  intervillous  spaces.     When  the  decidua  serotini 
is  affe<rte(l  the  result  is  firm  attachment  of  the  placenta  to  tii 
uterine  wall,  the  so-called  (i<l/iciruf  p/acoifd. 

In  the  other  two  forms  the  })lacenta  will  he  found  to  con- 
tain a  number  of  firm  fibrous  masses.  Occasionally  the  cen- 
tral portion  of  these  masses  may  undergo  a  cheesy  degenera- 
tion which  appears  very  like  })us. 

Tumors  of  the  Placenta. 

llarely  either  cystic  or  solid  tumors  of  the  i)lacenta  are  ni('t 
with. 

SypMlis  of  the  Placenta. 

The  syphilitic  ])lacenta  is  characterized  by  its  thickness 
and  density,  while  its  general  color  is  paler  than  normal. 
Scattered  over  its  surface  and  through  its  substance  aiv 
duMTv-like  nodules.  There  are  present  marked  fibroid  (h - 
generation  and  great  hypertrophy  of  the  villi. 

The  seat  and  extent  of  the  lesions  vary  with  the  mann(  r 
and  time  of  the  foetal  infection.  It  is  onlv  bv  a  nilrroscouifnl 
examination  that  a  placenta  can  safely  be  pronounced  sy|)li- 
ilitic. 

GBdema  of  the  Placenta. 

A  serous  infiltration  of  the  placenta  is  often  observed  \y\\]\ 
a  dead  and  macerated  fix»tus.  Interference  with  the  fital 
or  placental  circulation  may  also  produce  this  condition. 

Anomalies  of  the  Umbilical  Cord. 

Length :  The  cord  may  be  found  abnormally  long,  measnriiiL'^ 
as  much  as  seventy  inches,  or  abnormally  short,  measurinu 
only  two  to  four  inches.  Anomalies  of  insertion  of  the  c(»i(I 
have  already  been  mentioned. 

Coils:  The  cord,  if  it  be  of  unusual  length,  may  be  found 
encircling  the  limbs  or  neck  of  the  child.  It  is  most  fV<'- 
quently  coiled  about  the  neck  ;  in  extreme  cases  as  many  as 
six  or  eight  coils  may  be  present.  In  such  cases  asphyxia  is 
common. 


IDIOP. I  TllK  '  DISK.  1 SKS.  1  f)5 

Knots:  Wlicii  tlic  li(|ii()r  amnii  is  cxcossivo  and  the  con! 
iiiiMsiially  long  it  may  be  found  to  have  one  or  two  i\iiots, 
1  pinu'd  l)y  tlie  passajj^o  of  the  fo'tiis  through  its  looj)s. 
Ilarciv  this  results  in  the  death  of  the  f'letus. 

Hernia  into  the  cord:  A  ongenital  y>/o//w/.s'/o»  ot*  some  of 
till' al>dominal  viseera  into  the  sheath  of  the  umhilieal  cord  is 

asionally   met  with.      It  is  due  to  imjK'rfeet  development 

ot'  the  alxlominal  wall  at  the  seat  of  the  hernia. 


THE   FCETUS. 

Anomalies  and  Monstrosities. 

Teratology,  whieh  is  the  seienee  ])ertaining  to  f(etal  malfor- 
mations and  monstrosities,  forms  a  special  hrancrh  of  pathology, 
icferenco  to  which  must  he  ha<l  elsewhere. 

Such  malformations  of  the  fietus  as  interfere  with  the 
mechanism  of  labor  will  be  discussed  under  the  heading  of 
dystocia  of  foetal  causation. 

DISEASES  OF  THE  FCETUS. 

It  is  probable  that  foetal  mortality  excteeds  that  of  any 
otiier  ])eriod  of  life.  It  is  im])ossible  to  say  exactly  what  is 
tlic  f(Btal  death-rate,  as  actual  statistics  are  wanting;  but  that 
it  must  be  very  high  the  frecpiency  of  abortion  pi'oves. 
W'liitehead  has  stated  that  the  ratio  of  abortions  to  pregnan- 
cies is  1  to  7  ;  whil(!  Priestly,  from  a  study  of  the  niiscar- 
ri.iire-rate  in  the  well-to-do  classes,  considered  the  ratio  of 
nlMirtions  to  pregnancies  as  about  1  in  4^. 

lint  a  few  of  the  more  important  pathological  conditions 
allccting  the  foetus  can  be  referred  to  in  a  limited  work  of 
this  kind. 

Idiopathic  Diseases. 

Those  originating,  so  far  as  at  present  known,  in  the  foetus 
itself: 

Congenital  cystic  elephantiasis :  This  disease  is  characterized 
by  a  great  overgrowth  of  the  subcutaneous  connective  tissue 
ail  over  the  body.     At  intervals  in  the  hypertrophied  tissue 


1G6  PATHOLOGY  OF  PREGNANCY. 

cysts  aro  present,  wliicli  vary  greatly  in  size.     As  inalfoniui 
tions  of*  a  i>:ravc'  cliaracter  are   usuallv  associated  with  tlii- 
disease,  the  .-ubjccts  of  it  are  usually  boni  prematurely  iimi 
scarcely  ever  survive  the  birth. 

Anasarca:  General  anasarca  of  the  fcrtus  Is  occasionalK 
seen.  The  et>ndition  is  usually  associated  with  collections  ni 
fluid  in  the  plem-al  and  abdominal  cavities.  The  subjects  (t 
this  disease  are  usually  born  preniaturely  and  seldom  sur\iv( . 

Ichthyosis:  This  disease  is  observed  in  two  forms,  tin 
grave  and  the  mild. 

Thv,  (/rare  fonn  is  characterized  by  the  existence  over  tin 
whole  surface  of  the  body  of  horny  c])idermic  plates  separated 
from  each  other  by  fissures  and  furrows,  and  associated  \\iili 
deformities  of  the  face  and  extremities  which  lead  to  death 
of  tlic  infant  soon  after  birth. 

'.'he  iiu/d  form  is  characterized  by  the  presence  of  a  col- 
lodion-like substance  ovci  the  whole  body  of  the  fo'tus  which 
later,  by  a  process  of  descpiaination,  forms  into  flakes.  Jt  i- 
usually  associated  with  e(!tropion  and  eclabium.  Jt  does  not. 
as  a  rule,  prove  fatal,  but  may  ])ersist  more  or  less  throughoiii 
life,  or  mav  terminate  by  complete  cure. 

Witli  regard  to  the  <iiolo(/i/  but  little  can  be  said  beyf)n(l 
asserting  that  heredity  is  j)robal)ly  the  most  })owerful  factoi'. 

Treat nicnt:  AVarm  baths  and  iuiinctions  with  weak  anti- 
septic ointments  promote  sej)aration  of  the  scales.  J*erfc(t 
cleanliness  is  necessary  to  prevent  infection  of  the  fissinc.^ 
existing  in  the  skin. 

Rachitis:  That  tliis  disease  occasionally  occurs  dui'ing  in- 
fra-uterine life  is  believed  by  many.  C'hildrcn  ha\<!  b((  ii 
born  whose  bones  were  still  soft  and  easily  distortable  ;  wiiilr 
in  others,  in  whom  the  disease  had  jirobably  ))ursued  a  long<  i' 
course,  the  bones  were  thick  and  hard,  and  set  in  the  (h  - 
formed  sha])es  they  had  acquired  in  utero.  I'he  presence  nl" 
the  disease  In  the  foetus  has  been  held  to  account  for  tiio-c 
rare  cases  of  spontaneous  fracture  in  utero,  in  which  there 
has  been  no  history  of  external  violence. 


J 


FCETAi  srrniLis.  1G7 

Transmitted  Diseases. 

Those  due  to  diseases  in  tiie  parents : 

Foetal  Syphilis. 

This  is  probably  tlie  most  important  if  not  the  most  com- 
mon disease  of  intra-nterine  life.  Page  has  rep()rt(Ml  lliat 
s.>  |)er  cent,  of  premature  and  stillbirtiis  have  tiicir  cause  in 
s\  j)liilis  of  one  or  both  parents. 

Infectnn :  The  ovule  may  be  diseased  before  impregnation, 
wliere  the  woman  is  a  syphilitic.  Infection  may  occur  along 
with  impregnation  where  the  male  is  a  syphilitic.  Tiie  ftctus 
mav  become  irfected  at  any  period  of  intra-uterine  life, 
should  tlie  mother  contract  syphilis  while  i)regnant.  When 
the  infection  is  directly  paternal  in  origin,  the  syphilitic 
j)()ison  may  be  conveyed  from  the  fietus  to  the  mother,  and 
she  may  thus  develop  secondary  symptoms  of  the  disease 
witliout  a  primary  lesion.  It  is  undoubte<l  that  many  women 
give  birth  to  syphilitic  offspring  without  themselves  at  any 
time  manifesting  symptoms  of  the  disease.  The  likelihood 
of  development  of  the  disease  in  the  foL'tus  is  undoubtedly 
affected  by  the  period  of  time  since  the  acquisition  of  syphilis 
by  either  parent,  though  as  yet  no  limit  of  safety  has  been 
discovered.  The  author  i.'^s  met  with  a  case  where  the  dis- 
ease! had  remained  latent  in  the  father  for  twelve  years.  The 
mother  at  no  time  gave  evidence  of  syphditic  infection,  yet 
the  only  child  developed  well-marked  symptoms  a  few  weeks 
after  birth.  Hutchinson  has  reported  cases  in  which  women 
were  infected  near  term  and  gave  birth  to  syphilitic  infants. 

Manifestations  of  foetal  syphilis :  The  disease  produces  a 
great  variety  of  manifestations,  the  lesions  de})cnding  upon 
tli(!  tissues  attacked.  Thus  there  are  bullous  eruptions  of  the 
skin;  inflammations  of  mucous  and  serous  membranes; 
abnormal  development  of  connective  tissue  in  the  liver, 
kidneys,  lungs,  spleen,  etc  ;  and  a  characteristic  osteitis  and 
ost(Hichoudritis.  In  some  cases  the  infants  are  born  appar- 
ently healthy  and  only  manifest  symptoms  of  the  disease 
within  a  few  weeks  of  birth. 

Diagnosis :  Should  the  fcetus  be  born  dead  the  diagnosis  can 


168  PATHOLOGY   OF  PREd NANCY. 

be  made  with  certainty  by  a  few  perfectly  reliable  and  easily 
detected  si^ns. 

The  most  certain  sitrn  of  fetal  syphilis  is  to  be  found  in  the 
condition  of  the  dividing  line  between  the  diaphysis  and  ejMpli- 
ysis  of  the  long  bones — this  line  instead  of  being  shaip 
and  regidar  as  it  is  in  the  l^ealthy  infmt,  will  be  fonn<l  to  he 
Jagged,  broad,  and  of  a  yellow  coh^r,  due  to  an  osteochondri- 
tis. This  is  known  as  irc/y/u'y'.s'  «///;;  and  is  determined  h\ 
making  an  incision  over  the  trochanter  as  though  for  excision 
of  the  head  of  the  femur;  the  end  of  the  bone  is  then  turned 
out  after  cutting  its  ligaments,  and  a  median  section  of  the 
epiphysis  and  diaphysis  is  made  with  a  strong  cartilage  knife. 

The  liver  and  spleen  of  a  syphilitic  infant  are  always 
enlarged  as  a  result  of  connective-tissue  overgrowth.  For  a 
more  detailed  diagnosis  of  syphilis  in  the  infant  the  reader 
is  referred  to  other  works. 

The  treatment  of  fcetal  syphilis  consists  in  submitting  the 
mother  to  a  thorough  course  of  antisyphilitic  treatment 
throughout  pregnancy.  If  a  history  of  syphilis  in  either 
parent  be  obtained,  whether  occurring  before  or  subsequent  to 
conception,  the  woman  should  receive  throughout  the  preg- 
nancy antisyphilitic  treatment  as  a  prophylactic  measure. 

Other  Infectious  Diseases. 

A  large  ninnber  of  cases  have  been  collected  by  various 
observers  which  prove  the  possibility  of  contagious  diseases 
being  transmitted  from  the  mother  to  the  fnetus  in  utero. 
Rare  cases  are  recorded  where  children  have  been  born  with 
unmistakable  evidences  of  variola,  scarlatina,  measles,  ery- 
sipelas, malaria,  and  tyj)hoid. 

With  regard  to  tuberculosis  Hirst  states  that  there  is  ;i 
remote  possibility  of  the  passage  of  the  tubercle  bacilli  from 
mother  to  fetus ;  but  that  it  must  be  regarded  as  a  very 
exceptional  occurrence. 

Foetal  Death. 

The  death  of  the  foetus  in  utero  may  be  due  to  many  causes. 
Among  these  may  be  mentioned  syphilis,  acute  infectious  dis- 


THE   VULVA  AND   VAGiyA.  109 

cases,  iotorns  gravidarum,  malnutrition,  etc.  Tt  is  also  caust'd 
!)V  twisting  or  knotting  of  the  cord,  diseased  conditions  of 
llic  placenta,  or  by  trauma. 

Sequelae:  If  death  occur  before  the  second  month  the 
product  of  conception  may  be  entirely  absorbed.  In  the  later 
iiioiitiis  of  ])regnancy  the  fo'tus  may  undergo  maceration, 
iiiunHiiification  or  calcification.  Siiould  putrefaction  of  the 
(had  fo'tus  occur,  the  mother  may  be  involved  in  sepsis.  Tiie 
(lead  f(etus  is  usually  cast  out  of  the  uterus  in  a  short  time, 
tiiough  it  may  be  retained  for  years. 

PATHOLOGY  OF  THE  PREGNANT  WOMAN. 

The  Vulva  and  Vagina. 

Abnormal  conditions  of  the  vulva  or  vagina  during  ])reg- 
iiancy  are  generally  due  either  to  increased  blood-su})ply  or 
to  infection. 

Varices :  Obstruction  to  the  venous  return  offered  by  the 
enlarging  uterus  frequently  results  in  varicosed  conditions 
about  the  vulva  or  vagina;  these  varices  may  be  ruptured 
by  straining  or  by  a  blow  or  kick ;  severe  hemorrhage  may 
occur  and  has  proved  fatal. 

Treatment  consists  in  protection  by  means  of  a  snugly 
fitting  T-bandage,  and  rest    in  bed  with   the   hips  elevated. 

(Edema  may  occur  in  normal  pregnancy  sinijily  from  pres- 
sure of  the  uterus.  It  may  result  from  renal  insufficiency  or 
from  labial  abscess. 

Pruritus  of  the  vulva  in  varying  degrees  is  not  uncommon 
(hiiing  pregnancy.  It  may  be  C(tn.se(J  by  irritating  dischas.^cs 
or  may  be  a  neurosis. 

Tre((tment:  Cleanliness  and  tepid  injections  of  such  solu- 
tions as  the  following  :  borax,  ,^j  to  Oj  ;  acid,  carbolic,  1  :  200  ; 
or  zinci  acetat.,  .>ss  to  O j  ;  an  ointment  composed  of  chloral 
hydrate,  camj)hor,  aa  3ss,  ung.  aq.  rosre,  ^ij,  may  give  relief. 
In  severe  cases  it  may  be  necessary  to  aj)ply  solutions  of 
cocaine,  4  grains  to  the  ounce,  in  order  to  obtain  any  relief. 

Vaginal  leucorrhoea  may  be  very  troublesome  during  preg- 
nancy. In  all  cases  where  the  discharge  is  profuse  it  should 
l)e  examined  for  gonococci.    Simple  leucorrhoea  usually  yields 


170  PA  TIIOL  0 G  Y  OF  PREGNA  NCY. 

to  niikl  antiseptic  iistrinf»:eMt  douclies  which  should  be  given 
with  great  care,  c.(/.,  Coiidy's  fluid,  5J  to  Oj. 

Shouhl  (/onocorri  he  found  in  the  vaginal  discharge  the 
treatment  sliouid  he  energetic  :  hi(;]dori(le  (1  :  2000)  or  perman- 
ganate of  ))otassium  (oj  to  Oj)  douches  should  be  given  twice 
(laily,  and  an  occasional  a])j)lieation  to  the  walls  of  the  vagina 
and  urethra  of  a  solution  of  silver  nitrate  (gr.  x-xx  to  5J)  will 
])r()l)ably  give  good  results. 

Vegetations  of  the  vulva  sometimes  reach  excessive  size  dur- 
ing pregnancy.  Tiie  iradmenf  consists  in  washing  with  liquor 
sodie  cidorinatic,  afterward  dusting  with  calomel,  and  keeping 
them  perfectly  dry. 

The  Uterus. 

Tiiis  organ  may  in  pregnancy  be  displaced  forward,  back- 
ward, to  either  side,  or  downward. 

Retroversion  of  the  Gravid  Uterus. 

Causation  :  Tiie  displacement  is  of  frequent  occurrence  and 
may  have  existed  before  the  onset  of  pregnancy  ;  or  it  may 
occur  as  the  result  of  a  fall  or  sudden  jar. 

Anatomical  results:  As  long  as  the  uterus  is  less  than  foni- 
inches  in  length  it  may  lie;  across  the  axis  of  the  pelvis.  As 
its  bulk  and  lengtii  increases,  it  becomes  too  large  for  the  pel- 
vis. \i  upward  movement  be  prevented  by  the  projecting 
promontory  incarceration  occurs,  and  pressure  symptoms 
begin  to  develop.  Incarceration  usually  occurs  about  the  end 
of  the  third  or  the  beginning  of  the  fourth  month.  The  (lis 
tended  fundus  will  on  examination  be  found  to  occupy  the 
hollow  of  the  sacrum  causing  a  bulging  downward  of  the  pos- 
terior vaginal  wall,  while  the  cervix  is  ])ressed  upward  and 
forward  against  the  pubes,  thus  displacing  the  anterior  vag- 
inal wall  and  urethra.  The  bladder  is  thus  displaced  upwaril. 
Tiie  uterus  may  regain  its  normal  position  by  growing  u])ward 
in  the  direction  of  least  resistance  ;  or  it  may  remain  incar- 
cerated and  give  rise  to  serious  trouble. 

Symptoms :  The  earliest  and  most  distinctive  symptom  is 
dysuria,  accompanied  by  sensations  of  weight  and  bearing- 


i  .   I 


'■■■\ 


TREATMEXT  OF  RETROVERSION.  171 

(|(t\vii  pains.  If  tlio  coiKlition  bo  overlooked  or  noj:;lecte(l  the 
bladder  symptoms  become  rapidly  more  marked.  Ivetention 
ct'  urine  from  pressure  on  the  urethra  brings  about  overdis- 
icntion  of  the  bladder,  and  a  more  or  less  severe  cystitis 
results. 

While  the  urinary  symptoms  are  the  most  characteristic, 
ihc  condition  also  skives  rise  to  rectal  tenesmus  and  obstinate 
(•i»Msti])ati()n.  ( lOdcma  of  the  vulva  and  of  the  uterine  walls 
iiiav  develop  from  interference  \vith  the  pelvic  circulation. 
Tli(>  abdomen   becomes  distended  and   vomiting;  may  occur. 

Diagnosis :  \\  here  the  retroversion  is  suspected  the  bladder 
must  first  be  catheterized  before  makinu;  a  vaginal  exanuna- 
tion.     The  condition   will  then  be  readily  ascertained. 

The  history  of  retention  of  urine  and  dribbling  in  a  woman 
who  has  been  pregnant  for  three  or  four  months,  the  round 
(IdUghy-feeling  mass  occupying  the  vagina,  and  the  position 
(if  the  cervix  make  the  diagnosis  conclusive. 

Tiie  condition  may  be  siDiuhtfcd  by  ectopic  gestation,  sub- 
involution of  the  uterus,  intraperitoneal  luematocele,  uterine 
(ibroid,  and  ovarian  cyst;  but  careful  examination,  if  neces- 
MH-y,  under  an  ana}sthetic,  will  clear  up  the  diagnosis. 

Treatment  of  Retroversion. 

In  mild  cases  the  bladder  having  been  catheterized  and  the 
jKiticnt  placed  in  the  knee-chest  ])osition,  the  uterus  can  be 
i(  placed  by  ju'essure  upward  on  the  fundus  in  the  direction 
(if  one  or  the  other  sacro-iliac  joints,  so  as  to  avoid  the 
promontory,  two  iingcrs  being  placed  in  the  posterior  vaginal 
iornix  for  this  purj)ose.  If  necessary  the  cervix  may  at  the 
same  time  be  drawn  down  with  a  tenaculum.  If  the  attempt 
succeeds,  as  it  usually  does,  a  large  tam))on  should  be  ])laced 
ill  the  posterior  vaginal  fornix  to  retain  the  uterus  in  position. 
Tliis  may  be  replaced  later  by  a  large-sized  pessary.  If  the 
attempt  fails,  the  patient  should  be  placed  under  ether  and  a 
second  effort  made  to  replace  the  uterus. 

In  severe  incarcerated  cases  there  is  occasionally  great  dif- 
Hculty  in  emptying  the  bladder.  If,  after  drawing  down  the 
cervix  with  a  tenaculum,  the  catheter  fails  to  pass,  then  the 
l)laddcr  must  be  aspirated  by  suprapubic  puncture.     If  all 


172         PATHOLOGY  OF  PREGNANCY. 

attempts  at  reduction  fail,  then  abortion  must  be  induced.  If 
tlie  cervix  cannot  lie  reached  for  this  purpose  tluMi  the  uteriiu 
wall  must  be  |)nncliired  through  the  va_<j^inal  vault  and  tlu 
li([U()r  amnii  drained  away.  This  may  make  it  possible  t( 
draw  down  the  cervix,  which  should  then  b(!  dilated  and  tlu 
uterus  emptied.  Vaf>;inal  hysterectomy  may  be  necicssary  in 
rare  cases  where  suppuration  or  gangrene  of  the  uterine  wall 
has  occurred. 

Prolapse  of  the  Gravid  Uterus. 

Causation:  This  condition  may  occur  in  the  early  months 
of  ])regnancv  as  the  result  of  accident  or  from  violent  strain- 
ing when  the  vaginal  walls  and  outlet  are  greatly  relaxed. 

Treatment  consists  in  the  replacement  of  the  prolapsed 
organ  and  the  adjustment  of  a  perfectly  fitting  pessary  to 
retain  it. 

Endocervicitis ;  Tumors. 

Endocervicitis :  This  condition  is  frequently  found  during 
])regnancy.  It  may  be  the  origin  of  a  leucorrhooa  and  is  fre- 
quently associated  with  hyperemesis. 

It  is  best  irccded  with  ap])lications  of  fairly  strong  solutione 
of  silver  nitrate  (gr.  xx  to  3 j)  through  a  cylindrical  speculum. 
The  speculum  is  pushed  up  against  the  cervix  and  the  solu- 
tion then  jioured  in  and  allowed  to  remain  in  contact  for  at 
least  five  minutes. 

Uterine  fibroids  and  cancer  usually  com])licate  labor  more 
than  pregnancy,  and  will  therefore  be  dealt  with  under  thai 
head. 

Diseases  of  the  Breasts. 

Mammary  abscess  may  occur  during  i)regnancy  (see  Disecms 
of  Puerperal  Period). 

Excessive  secretion :  Occasionally  during  the  latter  part  of 
pregnancy  the  breasts  secrete  excessively,  causing  a  serous 
flow  which  gives  rise  to  considerable  inconvenience.  Appli- 
cations of  belladonna  may  afford  relief. 

Eczema  of  the  nipples  may  require  treatment,  though  the 
condition  is  very  obstinate. 


s 


PTYALISM,   OR  SALIVATION.  173 

DISEASES  OF  THE  ALIMENTARY  CANAL. 

Gingivitis  is  an  unpleasant  tliongh  sonicwliat  infrequont 
ailection  of  the  pregnant  woman.  Tliis  and  other  eon(litit)ns 
iibout  to  be  mentioned  are  due,  not  so  much  to  nncleanliness, 
;is  to  an  alteration  in  the  seeretions  of  tiie  Luecal  eavity  eon- 
-('(juent  upon  pregnancy.  The  (/nm.s  l)eeome  spongy  and  soft, 
p'd  or  violet  in  color  at  the  margins,  and  occasionally  ulcera- 
tion occurs.  Pain  on  eating,  foul  breath,  and  bleeding  are 
svmptoiAs  of  this  condition. 

Treatment:  Sometimes  <dno-ivitis  is  verv  obstinate  and  in 
spite  of  treatment  persists  through  pregnancy  and  even  lacta- 
tion. Astringents,  locally,  and  alkaline  tonics  give  the  best 
results.  Special  attention  in  the  way  of  cleanliness  as  regards 
tlie  mouth  and  teeth  should  be  observed  throughout  preg- 
nancy. 

Dental  caries:  There  is  a  common  saying  among  women,  \ 

"  for  every  child  a  tooth,"  so  fre(|uent   is  caries  of  the  teeth 
(jiiriui;  preucnancv.     All    dental    cavities    should   be   cleaned  \ 

out  and  tilled  temporarily,  as  prolonged   and  ])ainful  dental  • 

operations  are  to  be  avoided  during   pregnancy.     Syrup  of  i 

the  lactophosphate  of  lime   in  doses  of  .^j  t.  i.  d.  has  been  I 

r(^commended.  | 

Parotitis,  either  unilateral  or  bilateral,  is  an  infrequent  com-  j 

plication  of  pregnancy.  j 

Ptyalism,  or  Salivation. 

Occurrence:  This  is  a  not  infrecjuent  complication  of  ])reg- 
nancy.  It  is  generally  associated  with  extreme  nausea  and 
vomiting  in  highly  neurotic  women.  It  may  persist  through- 
out pregnancy,  beginning  as  early  as  the  second  month  ; 
some  cases  lose  as  much  as  a  quart  of  saliva  a  day.  Ptyalin, 
and  sodium  salts  are  diminished  or  may  be  absent  from  the 
saliva.  Frequently  these  patients  complain  of  j>ain  on  swal- 
lowing; and  the  submaxillary  and  sublingual  glands  become 
swollen  and  tender. 

Treatment  is  most  unsatisfactory  in  most  cases.  Co])ious 
rinsing  of  the  mouth  with  wealc  solutions  of  potassium  cldor- 
ate,  ash  bark,  cinchona,  etc.,  may  be  employed.     In  tlie  ex- 


174  PATllOLOdY  OF  PREGNANCY, 

perience  of  the  author,  local  measures  afford  but  little  if  any 
relief.  The  condition  is  a  ncnro.sis  and  nnist  he  treated  ;i> 
such.  Therefore  chloral  and  sodium  hrtimide  in  large  do.se^ 
may  be  tried  ;  atr()|)in(!  in  doses  of  gr.  ,,\^  t.  i.  d.  may  give  re- 
lief. What  rarely  tails  to  give  tenijyorary  relief  is  morj)hiii( 
(gr.  J)  with  atro])ine  (gr.  jlu))  ^^^^'^^  administered  together 
give  better  results  than  either  alone.  Tiie  latter  nnist  not 
be  given  as  routine  treatment,  but  oidy  occasionally  to  permil 
rest  and  sleep,  while  the  patient  should  always  be  kept  in 
ignorance  of  what  she  is  given  in  order  to  guard  against  tin 
formation  of  the  morphine  habit.  Antij>yrin  (gr.  v,  t.  i.  <l.) 
and  small  doses  of  cocaine  hydrochloi-ate  (gr.  ^,  t.  i.  d.)  have 
proved  useful  in  the  hands  of  some  jthysicians. 

Indigestion ;  Constipation ;  Diarrhoea. 

Indigestion:  Gastric  indigestion  is  very  common  in  the 
earliest  months  of  ])regnan(y.  If  careful  feeding  and  the 
ordinary  remedies  fail  to  give  relief,  chloral,  bromides,  and 
other  nerve  sedatives  should  be  resorted  to.  Intestinal  in- 
digestion may  give  rise  to  severe  abdominal  i)ains  and  may 
.simulate  appendicitis  or  even  extra-uterine  fo'tation.  1*11. 
aloes  et  asafcetid.'e  and  careful  dieting,  as  a  rule,  give  gooil 
results. 

Constipation  is  very  frequent  in  most  women  at  all  times. 
Care  should  be  taken  to  regulate  the  bowels  bv  careful  diet- 
ing  and  ordering  plenty  of  fluids.  Where  this  condition  is 
chronic  the  tablet  triturate  of  aloin,  belladonna,  cascara,  and 
strychnine  will  be  found  satisfactory;  active  ))urgatiou  is  to 
be  avoided. 

Diarrhoea  as  a  complication  of  ])regnancy  is  rare  ;  if  jiersist- 
ent  in  spite  of  ordinary  astringent  treatment,  nerve  sedatives 
will  probably  give  relief. 

Vomiting. 

Vomiting  is  one  of  the  commonest  disorders  of  the  digestive 
tract  occurring  in  ])regnancy. 

It  is  met  with  in  two  forms:  A  nhiiplc  x^omitlug,  which  is 
physiological;  and  jjej'niciouN  vomiting,  which  is  pathological. 


IJ 


PERNICIOUS   VOMITISa   OF  PREGyANCY.  175 

Simple  vomiting  of  pregnancy  lias  l)ccu  already  rof'erred  to. 
It  is  usually  present  during  the  eailicr  iiioiitlis  and  ceases  at 
the  end  of  the  fifth  month.  While  caiisiiin:;  distress  and  dis- 
comfort it  does  not  seriously  ini[)air  the  nutrition  of  preg- 
nant women. 

Pernicious  Vomiting  of  Pregnancy. 

This,  on  the  other  hand,  is  a  very  serious  condition,  which 
may,  if  it  resist  treatment,  j)lace  the  woman's  life  in  jeoj)ar(ly. 

Sjrmptoms:  This  uneontrollahle  form  ol'  vomiting  rarely 
hcgins  abruptly,  the  vomiting,  which  is  at  first  mild,  becoming 
gradually  more  severe  and  almost  constant.  I'ltimately  ab- 
solutely nothing  can  be  retained,  and  the  ])atient  rapidly  loses 
strength.  At  first  the  roviitcd  iiKttfar  consists  of  thick  nnicus, 
particles  of  food,  and  bile ;  later  only  blood-stained  mucus  is 
ejected,  and  the  retching  becomes  more  severe,  ej)igastric  ])ain 
(Icvelops,  and  there  is  great  aversion  to  foo<l.  Ptyalism  and 
(iiarrha^a  are  not  infrequent  at  this  stage.  The  patient  rapidly 
loses  strength,  becomes  mentally  de])ressed,  and  suH'ers  more 
or  less  constant  pain. 

If  the  condition  is  not  relieved  the  innpcraturr  rises  and 
the  patient  develops  symptoms  of  auto-intoxication.  The 
temperature  may  range  from  101°  to  103°  F.  and  the  ])ulse 
from  120  to  140;  the  extremities  become  cold  and  the  skin 
moist  and  clammy  ;  the  mouth  becomes  dry  and  the  patient 
complains  of  intense  thirst ;  sordes  a])])ear  on  the  teeth,  the 
tongue  becomes  coated  Avith  a  heavy  brown  fur,  and  the 
hreath  is  extremely  offensive.  '^Phe  urine  becomes  scanty, 
high  colored  and  offensive,  its  sj)ecific  gravity  is  high,  and 
it  contains  albumin  and  casts. 

Kmaciation  advances  rapidly  and  the  patient's  condition 
soon  becomes  serious  in  the  extreme.  Cerebral  symptoms, 
hallucinations,  delirium,  and  finally  coma  develop  shortly 
before  death  closes  the  scene. 

The  duration  of  the  malady  is  two  or  three  months,  but 
its  course  is  subject  to  intermissions  the  cause  of  which  is 
hard  to  explain.  The  symptoms  may  disa])pcar  for  several 
(lays  and  the  patient  give  evidence  of  improvement,  when 
suddenly  they  recur,  only  too  often  with  increased  severity. 


17G  PATHOLOGY  OF  PREGNANCY. 

The  etiology  of  pernicious  vomiting  is  very  obscure.  80 
many  factors  may  contribute  to  tlie  production  of  this  con- 
dition that  just  wliat  is  the  cause  in  any  definite  case  cnu 
rarely  be  stated.  Giles  has  pointed  out  that  probably  tiucc 
factors  enter  into  the  causation  of  the  ])hysiological  vomitinn' 
of  pregnancy,  namely  (1)  exalted  nerve  tension;  (2)  periph- 
eral nervous  irritation  arising  from  the  enlarging  uterus;  ainl 
(.'V)  an  easy  outlet  for  this  exalted  tension,  namely,  the  vagii-. 

Hv  the  exairireration  of  any  one  or  two  of  these  factoid 
l)ernicious  vomiting  may  be  produced.  Bearing  these  tiiivc 
factors  in  mind,  the  i)redi,spo,sin(/  cames  of  pernicious  vomit- 
ing may  be  grouped  as  follows  : 

(a)  Pr'n  III  parity.  In  primipara3  the  distention  of  the  womb 
is  accomplished  with  increased  difficulty  on  account  of  tlh' 
greater  tonicity  of  the  uterine  muscular  iibres. 

{b)  I-'reexisting  disease  of  the  uterus,  as  metritis  or  endo- 
metritis, or  displacements  of  the  organ. 

(c)  Disease  of  other  pelvic  structures,  either  preexisting  oi* 
coexisting,  as  salpingitis,  ovaritis,  etc. 

{(J)  Pathological  states  of  the  alimentary  canal,  as  gastric 
ulcer,  dyspe]>sia,  gastritis,  etc. 

(c)  Too  frequent  sexual  intercourse. 

(/)  IMental  or  ))hysical  shocks. 

{(f)  Toxic  conditions  of  the  blood,  urremia,  saprfemia,  etc. 

Recently  I  have  advanced  the  view  that  probably  the  essen- 
tial exciting  cause  of  the  nausea  and  vomiting  of  pregnaiicv 
is  the  phjislological  uterine  contractions.  It  is  well  known 
that  the  uterus  is  subject  to  rhythmical  contractions  through- 
out the  whole  period  of  pregnancy.  The  purpose  of  thc-c 
contractions  is  probably  the  acceleration  of  the  circulation  of 
blood  through  the  uterine  sinuses.  The  enormous  dilatation 
of  the  veins  of  the  uterus  which  occurs  as  the  result  of  preg- 
nancy brings  about  a  retardation  of  the  blood  flow  through 
them.  As  the  result  of  contraction  of  the  uterine  muscuhir 
fil)res  these  sinuses  become  emptied  of  blood  and  thus  the 
uterus  may  be  said  to  supplement  the  action  of  the  heart,  to 
wdiich  it  may  be  compared,  as  its  nervous  supply  is  very  simi- 
lar in  arrangement.  The  nerve  suj)ply  of  the  uterus  is  chieHy 
derived   from  the  ovarian  and  hypogastric  plexuses  of  the 


I 


PERNICIOUS    VOMlTISa   OF  I'liKGNANCy.  177 

,v\  iiijKitlu'tic  systoin,  wliicli  to  a  limited  cxti'iit  have  an  iiulo- 
iKiidciit  action  ;  while  in  tlie  inethilhi  there  exists  a  eentre 
|iicsi(lin<:;  (»vei'  uterine  contraction.  The  tle\(lo|>inent  oi"  the 
ciiihryo  and  its  envelopes,  as  well  as  the  hy|ter|»lasia  (d'the 
uterus  and  its  lining-,  are  accoiiijtanied  by  tremendous  ehemi- 
(■;d  changes.  Jt  is  eertaiidy  I'roni  the  venous  sinuses  at  the 
itLicciital  site  that  the  embryo  dei'ives  its  chi(!t'  nourishment 
;iii(l  into  which  its  efVete  mateiMal  is  emptied.  The  ordinary 
circulation  of  the  blood  throu<ih  the  sinuses  toa  certain  extent 
provides  for  ehangc  in  the  sup|)l» ,  but  o\\  in^"  to  the  retai'dation 
ut'  the  blood-eurrent  from  dilatation  of  these  sinuses  there 
iiiu>t  be  a  certain  rcsiduiun,  which,  as  it  becomes  surcharucd 
with  ell'ete  material,  probably  acts  as  an  irritant  and  stimu- 
lates the  uterus  to  contraction,  and  thus  to  a  cerlain  deoreo 
the  orjj^an  may  be  said  to  empty  itself. 

It  is  tliese  contractions,  so  brought  about,  which  probably 
prtuMpitate  the  paroxysms  of  nausea  and  xomitiu^.  UMie 
nausea  is  seldom  constant,  but  is  usually  rhythmical  in  its 
occiu'rencc.  As  has  already  been  stated  it  is  usually  most 
severe  in  the  morninfi;  when  after  a  lou^  fast  tiie  patient  as- 
siunes  the  erect  ])osition.  Jt  is  ])robable  that  the  occurrence 
(»f  the  retching  at  tliis  tiiue  is  due  to  the  eu^'or<rement  of  the 
|)elvic  circidation  consecpient  on  the  chanu'c  of  j)osture.  'I'his 
(.iitroro-ement  leads  to  excessive  uterine  contraction,  and  thus 
the  peripheral  irritation  is  inc^'eased.  [t  is  commoidy  noticed 
that  if  the  patient  partakes  of  food  bei'ore  risinji;  nausea  and 
vomitinjj  are  not  so  likely  to  ensue.  This  is  due  no  doubt  to 
the  enii-orirement  of  the  pelvic  veitis  beinj»;  reduced  by  the 
determination  of  blood  to  the  stomach  from  the  presence  of 
the  food  in  that  visciis. 

The  causes  mentioned  in  the  forep>lni«:  table  as  jircdisjmxitif/ 
to  perniei<Mis  vomitiiiir  |)robably  act  by  increasing  the  tendency 
to  contraction  on  the  ])art  of  the  uterus  (too  frecjuent  inter- 
course ;  nervous  shocks  and  toxic  conditions);  or  by  render- 
iiiu:  them  more  difficult  and  th(Tefore  increasins;  the  irritation 
they  cause  (primiparity  ;  metritis,  and  disease  of  neitj:hboring 
structures). 

The  prognosis  should  be  sxuarded  in  all  cases,  as  the  mortality 
ran<jjes  from  80  to  60  per  cent,  in  the  pernicious  form. 

I2-0b.<t. 


178  PATIIOLOUY  OF  I'llEdyASCY. 

Pernicious  Vomiting — Treatment. 

Dietetic  and  hygienic :  TluMlict  slmiiM  Ik;  li^lit  and  casilv 
(liucstihlc  ;  hdnrc  i'i>iiijj:  in  (lit'  iiioniiii^-  the  j)ati('iit  sIkmiM 
tal\('  a  ^lass  of  iced  milk  (»r  somo  li<»t  clear  coH'cc  or  wc;i|< 
tea.  Ill  sonic  cases  a  t^lass  of  sherry  and  ii  dry  biscuit  aiisw.  r 
tlie  purpose  \-ery  well. 

It  is  a  g'ood  |)lan  to  order  small  <(uaii(ities  of  plain  food  :it 
two-lioiir  intervals  dni'iii^  the  day,  instead  of  allowing  ilsc 
patient  three  regular  iiuals.  If  the  nausea  he  trouhlesoinc 
the  ])atieiit  should  he  kept  reclining  as  niiich  as  possihle, 
when  the  weather  permits,  out  in  the  opt'ii  air.  (lose,  wjiiiii 
I'oonis  and  tiuht  clotliiii»i,'  should  he  avoided,  and  atlentidii 
should  he  ^iven  to  the  condition  of  the  howels.  \\  hen  vom- 
iting;  occurs  only  in  the  ni(»rnini;  such  uieasur<'s  will  euallc 
tho  ]>atient  to  ])ass  the  day  in  comparative  coml'ort. 

When  vomitinii'  takes  |)Iace  several  times  a  day,  some  simiijc 
sedative  mixture  should  he  ordered,  such  as  the  followint>:: 

1^.  Sod.  hrom.,  gr.  xv  ; 

Aq.  camphorjc,  ,5ss. —  M.      O 

Sig.  t.  i.  d.  "H 

l; 
Kifervescent  hromocalTcine  in  drachm  doses  three  or  four  times 
dailv  often  I'enders  y^ood  service.      Iodine  or  carbolic  acid  in 
minim  tloses,  well  diluted,  may  he  tried. 

Patients  who  do  not  yield  to  the  above  treatment  should  he 
contined  to  bed.  A  thorough  examination  should  be  made  to 
ascertain  if  any  of  the  ))atliological  conditions  above  enunur- 
ated  as  ])redisp()sing  to  hyj)eremesis  gravidarum  are  present, 
and  if  so  appro])riate  treatment  should  be  inaugurated. 

\\'here  nothing  can  be  discovered  to  account  for  the  con- 
dition beyond  pregnancy,  the  stomach  should  be  given  n 
rest  and  rectal  alimentation  resorted  to.  Predigested  ini!k 
and  eggs,  nutrient  broths,  and  beef  peptonoids  may  be  ad- 
ministered per  rectum  every  six  hours. 

The  rectum  should  be  washed  out  at  least  twice  daily,  nnd 
immediately  afterward  a  pint  of  normal  saline  solution  should 
be  introduced  by  means  of  a  catheter  attached  to  the  no/.zic 
of  the  syringe,  high  up  into  the  bowel,  in  order  to  relieve  the 


KTEiirs.  170 

tiitiihic.'somc  thirst  wliu^li  is  usually  ju'csciit  iu  tlicsc  cax's. 
Tlio  uutrit'iit  cnt'iuata  should  lK'«:;iveu  very  slowly,  ainl  should 
inaT  consist  of  more  than  live  or  six  ounces.  Twice  daily 
an  eui'Mia  containinij;  chloi'al  hydrate.  (<ir.  xx)  and  sod.  hroui. 
(^r.  \1)  in  <)  ounces  of  niilU  shoidd  he  ij;iven.  Cold  packs  to 
the  spine  or  the  application  of  a  spray  of  ether  in  the  region 
ot  iIk;  fourth  or  fifth  dorsal  vertebra  may  prove  of  heiielit. 

N'carly  every  drug  in  the  pharniacopieia  has  hccii  rccoui- 
iiiiiid(!d  as  a  specific  in  this  eoudiiiou.     The   followiiiLr  ha\e 

I n  employed  with  siu^cess  by  many  :  antipyrin,  ij:;r.  v,  t.  i.  d.  ; 

tiiiiual,  \f\\  XV,  1).  i.  d.  ;  (!ocaiu,  ^r.  ^  hourly  till  live  doses  have 
h.cu  taken;  ac.  hydrocyanic,  dil.,  1l|iij  in  carbonated  water 
Mt'icr  food  ;  an<l  vin.  ipecac^  in  half-minim  doses  every  iiour 
for  several  dos(?s.  The  application  of  4  |)er  cent,  solution  of 
CDcaine  to  the  (^ervix  has  been  recommen<le<l  very  highly.  The 
;i|»|)lication  of  solutions  of  nitrate  of  silver,  jrr.  xx-\l  to  the 
(iiiiice,  after  the  manner  recommended  in  the  treatment  of 
ciidocervicitis,  has  many  a<lv()eates. 

( \)peiuan  first  reeoinmende<l  digital  dilatation  of  i\\o  cervix 
ill  the  treatment  of  this  condition,  ('ervical  dilatation  is  more 
( niiveniently  done  by  means  of  instruments,  either  !Ie<j^ar's  or 
(inudell's;  but  care  must  be  taken  not  to  rupture  the  mem- 
l)i;nies.  This  treatment  is  uncertain,  and  is  therefore  not  to  be 
ivcoMunended. 

Ill  rare  cases  it  is  necessary  to  induce  abortion  in  order  to 
save  the  patient's  life.  It  is  a  dilHcult  (piestion  to  decide  just 
when  one  is  justifi(!<l  in  terminatinuj  the  preini:nancy.  If  rectal 
alimentation  fails  after  a  fair  trial  and  the  patient  is  absolutely 
iiiiai)le  to  retain  anything  on  the  stomach  ;  if  the  pulse  rises 
to  120  and  ])rostration  becomes  marked,  then  the  sooner  the 
uterus  is  emptied  the  lietter. 

This  procedure  should  never  bo  adopted  without  the  sup- 
port of  a  competent  consultant. 

Icterus. 

Jaundice  is  occasionally  met  with  in  pre2:nancy.  It  may 
result  from  o:astro-intestinal  catarrh,  from  ])liosj)horus-poison- 
iiiiz',  or  from  obstruction  of  the  bile-duct  due  to  the  pressure 
of  an  overdistended  uterus.     The  development  of  gall-stones 


180 


PATIIOLOaV  OF  PREG NANCY. 


ill  inv<::iKiiH'y  is  of  soinowluit  fre(|nont  oooiirrcnco.  A  .so*.  (  re 
form,  icfrriis  (/rdr'is  (intrhhtrnm,  is  of  vtjrv  rare  occiirrcDci'.  It 
is  nearly  always  fatal,  and  is  iliie  to  an  acute  deir^'ncration  ■  i' 
the  whole  hepatie  structure.  Acute  detieneration  ol'  the  li\.  r 
and  icterus  are  not  infre(|Ueiit  in  eclanii)tic  cases. 

Icterus  endangers  to  a  \\'\\r\\  dei::ree  the  life  of  the  fcetus,  !iv 
l)rinirin<j^  on  abortion  or  by  the  injurious  action  of  the  bile 
salts.  Not  infrecjuently  the  li(|Uor  aninii  and  fetus  are  stain  (| 
by  the  coloi'ini!;'  niattei-  ot   the  bile. 

Treatment:  In  mild  cases,  warm  alkaline  baths  and  caloiii'l 
associated  with  mild  j)urL!:ative  waters  are  indicated.  In  \fv\ 
severe  cases  the  induction  of  abortion  slu,-iild  be  considei*  d, 
os])ecially   if  the  fcetus  is  viable. 

Hemorrhoids. 

'I'he  j)elvic  conii^estion  of  j)reii;'nancy  and  the  ])ressure  of  the 
j^ravid  uterus  predispose  to  this  troublesome  affection. 

Treatment  can  only  b(>  palliative.  Laxatives,  rest  in  ind, 
and  the  fre(|nent  assumption  of  the  knee-chest  posture  will 
afford  i-elief.  Locally,  unir.  ualke  cum  opio,  or  hot  su<i;;ar  nf 
lead  lotions,  may  be  serviceable.  Suj)positories  containiiiu 
opiiun  (ijr.  \)  an<l  ext.  hamamelidis  (gr.J)  nuiy  bo  enipioycd 
if  tlio  pain  is  severe. 

J)ISEASKS  OF  THE  URIXAllY  SYSTEM. 


The  Bladder. 

Irritability  of  the  bladder  is  a  fre(|uent  functional  disocdcr 
of  i)reu'nancv.  It  is  irenerallv  relieved  bv  the  adminislraiinn 
of  alkaline  sedative  mixtures. 

Haematuria  may  occMir  durintr  ])re<rnancy,  and  is  j^jencrnlly 
associated  with  vesi<'al  hemorrhoids.  If  severe,  the  b/laddcr 
shon'd  be  wjished  out  daily  with  a  weak  solution  of  silver 
nitrate  (jiT.  ss-j  to  .^j). 

Scanty,  hif,h-colox'ed  urine  liavintr  a  hiii:h  sj)ecific  i:ra\ily. 
results  "rom  indiscretion  in  diet,  and  is  .issoc'ated  with  iuacti\- 
't;,  of  the  skin  and  bowels;  this  condition  of  the  urine  .should 
always  receive  attention.  A  non-nitrogenous  diet,  laxatives, 
and  copious  draughts  of  water  should  be  ordered. 


THE  KIDSEYS.  181 

Albuminuria  is  fbiuid  in  from  5  to  G  pcM*  cent,  of  pivgimiit 
\vi linen,  and  is  usnally  associated  with  kidney-eliang^s  due  to 
jtntiiu'iicy,  or  nej)hritis. 

The  Kidneys. 

Kidney  of  pregnancy;  There  exists  undoubtedly  a  chronic 
form  of  renal  disease  wiiich  is  dependent  on  jn'egnaney,  and 
w  lii(  Ii.  as  a  rule,  does  not  give  rise  to  serious  disturbance  of  the 
IKiiicnt's  general  health.  It  is  usually  •i.ssociated  with  albu- 
iiiinnria  and  subsides  rapidly  ai'ter  j)arturition.  it  is  impor- 
tant, as  it  ])redisposes  to  the  develoj)ment  of  the  condition  of 
(■rlainj)sia,  in  so  far  as  it  interferes  with  the  proper  iunction  ol' 
tlii^e  important  excretory  organs. 

Frequency  :  As  ali'cady  stated,  albuminuria  is  present  in  from 
")  to  0  |)er  C(>nt.  of  all  cases  <»f  pregnancy  ;  but  it  is  probable 
that  a  far  larger  pro))ortion  of  cases  liave  some  degree  of  icnal 
iii-ulli(!iency,  though  albumin  may  not  be  j)resent  in  the 
iii'iiic. 

Pathology:  The  kidneys  are  usually  amemic,  and  ])resent 
evidences  of  fatty  infdti'ation  of  the  epithelial  cell.-  \\ilh(»ut 
intlammatory  changes. 

Symptoms:  The  condition  is  not  infreipiently  met  Avith  in 
|)iiinij)ane.  The  symptoms  usnally  manifest  themselves  in 
the  latti'M-  half  of  the  pi-cgnancy,  and  ai'c  generally  mild, 
ilcadaciie,  j)allor,  weakness,  and  slight  shoriness  of  bi'cath 
arc  usually  the  oidy  subjective  mainfestations.  The  irr'na  is 
lessened  in  (piantity,  is  cleai",  .ind  its  spc<'itic  gravity  is  re- 
(liicrd  ;  it  contains  from  a  (pun'tcr  to  one-half  its  bulk  of 
allHiinin,  and  a  +'ew  granular  casts  ;  the  albumin  is  mainly 
paraglobnlin.  The  >irc<i  daily  excr'eted  is  generally  below 
the  average  of  liealth  ;  generally  the  lower  the  in<iex  of  urea 
the  more  marked  are  the  ]>atient's  sympt(»ms.  Delivery  is 
followed  by  diuresis,  which  is  most  marked  from  the  third  to 
the  fifth  day. 

Etiology:  The  cause  of  the  condition  is  pi-obably  a  diminu- 
tion of  the  l)lood-sup|)ly  due  to  inci'eascd  inti'a  abdominal 
tension  ;  and  to  irritation  froir  the  excess  of  effete  substances 
contained  in  the  maternal  blood. 

Treatment  is  as  that  ibr  true  nej)hritis. 


182 


PATHOLOGY  OF  PREGNANCY. 


Acute  and  Chronic  Nephritis. 

Tliese  diseases  are  more  prone  to  occur  during  pregnane  v 
oil  account  of  the  extra  amount  of  work  devolving  upon  the 
Uiduevs  at  tliis  period. 

Tile  symptoms  are  tlie  same  as  in  cases  not  complicated  l.\- 
pivguaney. 

Differential  diagnosis:  It  is  not  always  easy  to  differentiiiio 
between  the  kidney  of  pregnancy  and  chronic  nephritis;  hiii 
the  following  ditferential  signs  may  jirove  of  aid: 


History. 

Kidney  of  Pregnancy. 

Chronic  Nephritis. 

Kidneys     normal     before 

Existed    before    pn^'- 

prej^nancy. 

nancy. 

Quantity  of  urine. 

About  normal  or  slightly 
lessened. 

Increased. 

Specific  gravity. 

Low. 

I.,ow. 

(Jasts. 

Few  and  only  with  severe 

Numerous  and  appiar 

symptoms. 

early  in  pregnancy. 

Retinitis. 

Absent. 

Very  often  present. 

Grave  symptoms. 

Generally  appear  in  later 

May    be     pronouncd 

months  of  pregnancy. 

in  early  months. 

Ceases  with  parturition. 

Persists  after  parturi- 

tion. 

Prognosis:  Tlie  possibility  of  complications  renders  tlio 
prognosis  for  the  mother  doubtful,  while  as  regards  the  child 
it  is  decidcdlv  s;rave  on  account  of  the  tendencv  to  the  forma- 
tion  of  })lacental  infarctions.  Premature  interruption  of  tlie 
pregnancy  is  also  of  frecpient  occurrence. 

Treatment:  As  it  is  important  to  know  the  condition  of  tlio 
kidncivs  in  jiregnancv,  frecpient  examinations  of  the  urine 
should  be  made.  Should  evidences  of  renal  insufficiency 
))resent  themselves,  the  patient  should  at  once  be  placed  u\^nn 
a  dietetic  and  hygienic  regimen.  Meat  should  be  excnidc*!, 
and  the  diet  consist  of  milk  and  farinac;'oiis  foods;  lariic 
draughts  of  water,  preferably  Poland  or  lithia  water,  slioiiM 
be  systematically  taken.  The  patient  should  be  guarded 
against  fatigue  and  exposure  to  cold  or  damjmess.  A  saline 
laxative  should  be  administered  two  or  three  times  a  week. 


(!'( 


DISEASES  OF  THE  RESPIRATOIiY  SYSTEM.         183 

Should  the  (jiiantity  of  tl»o  urine  excreted  not  increase,  and 
Icnia  appear,  the  jjatient  should  then  i)e  placed  on  an  ex- 
clusively milk  diet  and  he  put  to  l)ed  ;  a  diuretic  mixture 
should  he  ordered,  such  as  Jkisham's  mist,  ferri  et  annnon. 
iiif'tatis,  U.  8.  P.,  in  5ss  doses  after  meals. 

If  un<ler  tiiis  treatment  the  symptoms  grow  gradually 
worse,  then  the  termination  of  pregnancy  is  necessary.  When 
;i!l»umimiric  retinitis  develops,  ahortion  uuist  at  once  he  in- 
duced if  the  ])atient's  life  is  to  he  saved,  hence  the  importance 
oi'  an  ophthalmoscopic  examination  in  all  cases  in  which  ob- 
scurity of  vision  is  a  symptom. 

DI8EA8E8  OF  THE   RESITRATORY   t^YSTE.M. 

Cough,  with  or  without  evidence  of  bronchial  catarrh,  is  a 
very  common  and  occasionally  troublesome  ailection  <luring 
id'ciTuancv.  The  rcHex  cout^h  of  i)reu'uancv  mav  be  verv 
persistent,  and  when  the  j)aroxysms  are  severe  and  continuous 
mav  lead  to  abortion.  In  its  frcafinoif  autis|)asmodics  and 
.-(datives  are  indicated  rather  than  exinrtorants.  Jiromide 
of  sodium  and  tr.  belladonnie  in  combination  give  good  results, 
a-  do  also  drachm  doses  of  the  linctus  codeia. 

Dyspnoea  occasionally  occurs  as  a  reflex,  and  may  cause  the 
patient  considerable  distress.  It  is  m(»re  tre<|uent  in  the 
later  months  of  pi'egnancy,  when  it  is  genei-ally  due  to  over- 
(listention  of  tiie  abdomen  and  mechanical  pressure  of  the 
uterus  upon  the  (liaj)hragm.  In  the  former  class  of  c:ises 
sedatives  are  indicated  ;  wiiile  in  the  latter  relief  may  be  o!>- 
taiued  by  avoiding  tigh*^  clothing,  and  having  the  patient 
sleep  with   the   head   and   shoulders   elevated. 

Pneumonia  is  a  disease  much  to  be  dreaded  when  complicated 
h\  pregnancy.  The  Hij^nptoms  are  always  aggravated  and  the 
mortality  for  both  mother  and  fictus  is  high. 

Phthisis  pulmonalis :  Pregnancy  has  a  most  unfavorable  in- 
tliience  on  this  disease.  Rarely,  patieiits  sutfcring  frouj  j)hth- 
i-is  seem  to  improve  during  pi'egnancy  ;  !)ut  the  disease  only 
advances     the     more    raj)idly    after    delivery    has    occurred. 


184         PATHOLOGY  OF  PREGNANCY. 

AVomen    alreiuly   affected    niul    j)re(li.s[)osed    to   tuberculosis 
should  he  strongly  advised  against  maternity. 

DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Cardiac  diseases  in  pregnancy  are  not  rare ;  the  danger  of 
the  heart  lesions  is  increased  by  pregnancy  ;  abortion  is  api 
to  occur  from  tiie  formation  of  infarctions  in  the  i)lacenta  ; 
not  infrequently  the  child  is  l)orn  badly  nourished. 

Tlic  cotiiplications  to  be  dreaded  are  failure  of  comjiensation 
due  to  fatty  degeneration;  and  })ulnionary  congestion.  1 1 
compensation  is  good,  no  untoward  symj)toms  are  likely  to 
develo]),  beyond  fi'dema  and  albuminuria,  the  latter  boiiiu 
due  to  renal  congestion.  Hirst  states  that  witli  proper  treat- 
ment he  has  no  fear  of  heart  disease  in  pregnancy. 

Treatment:  All  women  sutlei'ing  from  cardiac  disease 
should  be  kept  under  constant  observation  tlu'oughout  gesta- 
tion. The  urine  should  be  frecpiently  examined.  Sliould 
symptoms  of  failure  of  compensation  arise,  digitalis  and 
stropiumthus  should  be  exhibited,  combined  with  strychnine  ; 
the  bowels  should  be  kept  open,  and  rest  and  moderate  ex- 
ercise ordered. 

Hirst  states  that  pregnancy  should  not  be  allowed  to  con- 
tinue longer  than  the  thirty-sixth  week  in  a  woman  who  ex- 
hibits any  symptoms  of  imperfect  compensation.  Cardiac 
diseases  do  not  contraindicate  the  employment  of  ana?stiietics 
during  labor.  These  benefit  by  preventing  the  injurious  effects 
of  straining  and  by  quieting  the  action  of  the  heart  during 
parturition. 

Functional  heart-murmurs  in  pregnancy  :  In  the  later  montlis 
of  pregnancy  soft,  I  lowing  murmurs  can  occasionally  be  heard, 
both  over  the  mitral  and  aortic  areas  ;  these  are  usually  sys- 
tolic in  rhvtiim,  but  mav  also  be  diastolic.  They  mav  he 
ex))lained  by  the  hydrjcmic  state  of  the  blood  in  pregnancy, 
and  may  in  ])art  be  due  to  a  certain  amount  of  displacemein 
of  tlie  organ  resulting  from  overdistention  of  the  abdomen. 
They  disappear  completely  shortly  after  labor. 

The  bloodvessels :  Varicose  conditions  of  the  ven..    of  the 


NEUROSES.  185 

ixlvis,  alKloniinal  walls,  and  lower  limbs  are  froquont  during 
])ii'<riuuKiy.  i'hey  result  in  jiart  from  (;lianges  in  the  vessels 
themselves,  and  in  j)art  from  the  mechanical  obstruction  to 
the  circulation  offered  by  the  increasing  bulk  of  the  uterus. 
Ti-'atmcnt  consists  of  elastic  suj)i)()rt  where  this  is  possible, 
ami  in  the  avoidance  of  constipation. 

Enlargement  of  the  thyroid  gland :  The  fact  that  there  exists 
a  ])eculiar  relationship  between  the  thyroid  gland  and  the 
utri'us  aivd  general  circulation  is  well  known.  Usually  a 
svinj)athetic  growth  of  this  gland  occurs  at  the  same  time  as 

eiihirgement  of  the  uterus  ;  hence  the  fulness  of  the  n(!ck  so  j 

often  noticed  in   pregnant  women.     Thus  in   simj)le   and  in  -^ 

exi>j)hthalmic    goitre    pregnancy    exerts    a   very   inifavorable  | 

influence.     The  growth  of  the  gland   may  progress  to  such  a  \ 

degree  as  to  cause  pressure  ui)on  the  trachea  resulting  in  dysj)-  | 

mea,  and  even  threatening  maternal  death  from  asphyxia.     In  | 

rare  cases  tracheotomy  has   been   resorted  to  in  order  to  save  \ 

the  patient's  life.  | 


DISEASES  OF  THE  NERVOUS  SYSTEM. 

Neuralgia  in  various  portions  of  the  body  is  a  fref|uent  af- 
fection of  the  pregnant  woman.  The  most  common  situations 
arc  the  head,  hands,  face,  teeth,  and  breasts.  Pelvic  neuralgia 
is  usually  due  to  j)ressure  of  the  growing  uterus  uj)on  the 
j)elvic  nerves;  occasionally  neuralgia  occurs  in  the  uterus. 

f n  the  frcdfiiinif  of  these  troublesome  neuralgias,  tonics  con- 
taining iron,  fpiinine,  and  arsenic  are  j^articularly  valuable. 
Attention  should  always  be  paid  to  tiie  matter  of  diet,  sleep, 
and  the  state  of  the  emunctories  in  these  cases.  Any  of  the 
coal-tar  derivatives,  combined  with  the  citrate  of  catfeine  to 
prevent  depression,  usually  ])romptly  relieve  the  severe  pain. 
All  sources  of  local  irritaticm  should  be  sought  for  and  re- 
moved. 

Neuroses. 

Chorea  :  Mild  grades  of  chorea  cannot  be  said  to  be  uncom- 
mon in  pregnancy.     Chorea  is  more  common   in  primipurge. 


186  PATHOLOGY  OF  PREGNANCY. 

Rh(niinati.sni,  clilorosis,  lioredity,  and  tlio  previous  ocnurronr 
of  tlu!  disease  in  ciiildliood  are  considered  as  predisposing: 
causes.  Jt  usually  a[)j)ears  early  in  pregnancy  and  is  a})t  tu 
persist  throughout  its  cronrse.  As  a  rule,  in  the  milder  ca<(< 
it  does  not  manifest  itself  dui'ing  sleep.  In  the  grave  forin 
it  may  result  in  the  j)atient's  death,  after  causing  preniatm  ■ 
exjndsion  of  the  ovum. 

The  treatment  is  the  same  as  when  not  complicated  hy  pr(>o 
nancy. 

Epilepsy  is  a  rare  complication  of  pregnancy.  It  does  noi, 
as  a  rule,  exert  an  uni'avorahle  inlluence  upon  the  course  ol' 
gestation,  and  it  can  usually  he  controlled  by  the  free  admin- 
istration of  ])otassium  iodide. 

Hysteria  is  frequent  during  pregnancy. 

Vomiting  and  coughing  occur  as  neuroses  during  pregnancy, 
and  have  already  been  referred  to. 

Psychical  disturbances :  Not  uncommonly  a  complete  change 
in  the  disposition  and  mental  character  of  the  woman  m:iy 
occur  during  j)rcgnancy. 

Insomnia  may  be  ti'oublesome  toward  the  close  of  j)regnancy. 
A  warm  bath  on  retiring,  a  glass  of  milk,  or  a  cup  of  warm 
broth,  taken  at  the  same  hour,  may  be  sufficient  to  induce 
sleep;  sidphonal  or  trional  in  10-  to  15  grain  doses  may  he 
resorted  to  if  recpiired. 

Insanity  is  of  but  rare  occurrence  during  gestation,  beiiiL: 
much  more  likely  to  develop  during  the  puerperal  ])erioil. 
jNIelancholia  and  mania  are  the  more  usual  forms,  the  former 
being  more  frecpient. 

The  j)rof/)i()sis  in  the  maniacal  form  is  more  grave  than  in 
the  melancholic.  Insanitv  mav  recur  in  successive  i)i'eu- 
nancies.  It  may  be  stated  that  gravidity  exerts  usually  an 
unfavorable  inHuence  upon  insanity. 

The  treatment  can  only  be  expectant  and  symptomatic;  in- 
duction of  labor,  when  marked  symptoms  liave  developed,  only 
tends  to  aggravate  the  condition. 

Temporary  delirium  may  occur  during  labor,  and  is  far  from 
common.  A  woman  rendered  delirious  from  acute  suH'ering 
in  labor  may  do  serious  injury  to  her  child,  for  which  she 
cannot  be  held  responsible. 


INFECTIOUS  DISEASES.  187 

DISEASES  OF  THE  CUTANEOUS  SYSTEM. 

Herpes  gestationis  is  a  peculiar  neurotic  skin  affection  usu- 
ally met  witii  in  early  pregnancy.  It  generally  ])ersists 
throughout  gestati(»n  in  spite  of  treatnuMit.  The  eruption  is 
iiiiiltitbrin,  exhibiting  erythema  vesicles  and  hulhe.  lis  treat- 
ment consists  in  the  administration  of  nerve  sedatives  and  the 
1.  julation  of  the  diet  and  mode  of  life  of  the  patient. 

Impetigo  herpetiformis  is  rare.  It  usually  occurs  toward  the 
close  of  pregnancy.  It  generally  locates  itself  in  the  folds 
of  the  body  around  the  groins,  the  und)ilicus  and  axilla',  and 
iiiider  the  mamnife.  It  occurs  as  small  ])ustules  forming 
crusts ;  it  tends  to  spread  raj)idly  and  may  cover  the  whole 
Ixxly.  It  is  generally  accomj)anied  by  marked  syni])toms  of 
-ystemic  disturbance,  high  fever,  chills,  vomiting,  and  severe 
piostration.  Hirst  states  that  of  twelve  cases  ten  terminated 
iiitally.  The  disease  did  not  terminate  gestation  prior  to  the 
maternal  death. 

The  ii-cidmeni  is  symptomatic,  with  the  apj)lication  of  sooth- 
ing remedies  locally. 

Pruritus  is  usually  a  local  affection  limited  to  the  vulva ; 
i)nt  it  may  occur  as  a  general  affection.  It  may  cause  intense 
siilfering  to  the  patient,  and  eases  have  been  reported  in  which 
it  was  necessary  to  induce  labor  in  order  to  relieve  the  ])atient. 

Treatment  consists  in  alkaline  baths  (o  ounces  of  bicarbonate 
(if  sodium  to  the  bath),  and  frictions  with  sedative  lotions,  as 
the  camphor  or  chloroform  liniment.  Usually  this  treatment 
must  be  combined  with  the  internal  administration  of  chloral 
aiifi  bromide. 

Exaggerated  pigmentation  :  Dark  spots  of  ]iigmentntion  may 
aj)j)ear  on  the  breasts,  thighs,  and  abdomen,  and  occasionally 
on  the  face.  The  condition  is  not  amenable  to  treatment,  and 
usually  disappears  shortly  after  labor. 

Infectious  Diseases. 

Certain  of  the  infectious  diseases  are  more  prone  to  attack 
the  pregnant  woman  than  are  others. 

Variola  is  ])r»)bably  the  most  virulent  of  the  infectious  dis- 
eases attacking  the  ])regnant  woman.  It  generally  results 
speedily  in  both  fa'tal  and  maternal  death. 


188  PATHOLOGY   O.     PRKaNAydY. 

Scarlatina  is  upt  to  ho  exocodiii^ly  virulent,  hut  it  is  moiv 
prone  to  attack  the  puer|teral  woiiiim. 

Measles  in  tiie  prei>ii;uit  woniaii  usually  assumes  a  s(,'vr'r( 
ty|)e  and  <r('nerally  leads  to  ahortion.  The  patient  exliihits  a 
marked  tendency  to  develo})  pneumonia  as  a  comj)lieati()n. 

Typhoid  fever  does  not,  as  a  rule,  tend  to  assume  an  unusual h 
sev(>re  tyi)e  when  it  attacks  the   |)re<iiiaut  woman.     'I'lie  ju-o- 
longcd  elevation  of  temp(M'ature  tends  to  hringahout  ahortion 

TOXEMIA— ECLAMPSIA. 

Definition  :  Eclampsia  is  a  disorder  of  pregnancy  character- 
ized hy  epih^ptiform  convidsions,  and  depending  u[)on  tlic 
retention  within  the  hody  of  toxins.  The  term  is  derived 
from  the  (ireek  zxlan.ifi^,  a  shining  forth.  The  convulsi\c 
seizures  may  occur  during  pregnant.'v,  lahor,  or  the  j)iierp(ral 
period,  though  they  are  most  fre(piently  associated  with  hihor. 

Frequency:  It  oc(!urs  about  oni-e  in  -"MH)  cases  of  pregnancy. 
It  is  more  fre(piently  met  with  in  primipai'ie,  especially  in 
those  illegitimately  ])regnant  and  in  those  over  thirty  year- 
of  age.  In  multigruviche  it  is  more  commonly  associated  with 
multiple  j)reguan(!y,  and  with  exposure  to  dampness  and  eoM 
in  women  of  the  poorer  class(\s  who  ar(?  underfed  and  over- 
worked. Women  who  are  deti(Ment  in  action  of  the  skin,  kid- 
neys, and  bowels  are  good  subjects  for  eclampsia  should  tliey 
become  pregnant. 

Eclampsia— Symptoms. 

Premonitory  symptoms  usually  manifest  themselves  sonic 
time  before  tiie  ecdam])tic  convulsion.  These  are  :  a  condi- 
tion of  irritability  and  heaviness;  frontal  headache;  dis- 
ordered vision;  and  diminished  secretion  of  urine.  Occa- 
sionally (cdema  of  the  face  and  limbs  is  present;  and  imt 
infre(piently  more  or  less  severe  e))igastric  j)ain.  The  general 
vascular  tension  is  usually  markedly  increased.  Rarely 
eclamj>sia  occurs  without  any  premonitory  syjiiptoms. 

The  urine  is  diminished  in  (|uantity  to  from  one-half  to  one- 
third  the  average  in  bealth.  The  K}>ccijic  f/nirifii  is  very  high, 
from  1030  to  1045  ;  in  rare  eases  it  may  be  lower  than  nor- 
mal, 1010  ;  and  the  cpiantity  of  urine  undiminished. 


ECLAMPSIA.  189 

Alhnmin  is,  :is  ii  rule,  pivsciit  in  tlu  iii-iiio  in  very  lai'<ije 
(|iiantiti'  -,  tli()ti<!;li  it  may  in  I'arc  cast's  he  aWscnt.  Tlic  alhii- 
iiiinoii  |H't'(i|»itat('  is  cdniiyosi'd  ol'  sci'inii-allxnnin  and  |>ara- 
'jlitlmlin.  riic  presence  ot"  lai'ue  <|iiantilies  of  serinn-alWuinin 
ill  the  urine  indicates  verv  extensive  dainatie  to  tlie  renal  ceils, 
i:i  wiiieii  case  tiie  j)r()n;n()sis  is  rendered  more  sei'ions. 

I'o  distinguish  the  relative  amoiuits  of  the  two  kinds  of 
.illnunin,  the  urine  nuist  lirst  he  saturated  w.th  mairnesium 
-iilphate  to  precipitate  the  paraiilohidin.  After  lilterinu-,  the 
liltrate  mav  be  tested  ior  senmi-alhiunin  i)v  the  niti'ic-acid  or 
licat  test.  The  j)recipitate  obtained  iVom  the;  filtrate  may 
then  be  compared  witli  that  thrown  down  by  lieat  oi*  nitrlt; 
;iiid  in  a  spi'cimen  w  liich  has  not  been  satiM'uted  with  magne- 
siimi  sulphate,  and  the  dilference  noted. 

rrca  is,  as  a  rule,  largely  diminished,  not  only  in  quantity, 
but  also  in  })ercentag:e. 

( '«.s/.s  may  or  may  not  be  found  in  the  urine. 

LeiU'in  and  fi/rosiii,  if  sought  for,  will  usually  be  found  in 
the  urine  of  eclamptics. 

The  eclamptic  fit  usually  begins  with  a  fixed  expression  of 
the  (yes,  the  hea<l  being  tui'ued  to  one  side  ;  th(!  eyelids  twitch 
rapidly,  the  ])upils  contract,  and  the  eyeballs  roll.  The  spasm 
of  the  muscles  then  sj)reads  ra))i<l'v,  the  mouth  is  <lrawn  to 
one  side,  the  jaws  clench,  ol'ten  causing  severe  injury  to  the 
tdiigue,  which  may  be  caught  between  the  teeth  ;  the  head  is 
rolled  rapidly  from  side  to  side  and  then  di'awn  back  ;  as  the 
muscles  of  the  trunk  and  limbs  become  affected  the  whole 
body  is  thrown  into  a  condition  of  tonic  spasm.  As  resj)ira- 
tion  is  interferc<l  M'ith  the  face  becomes  livid  and  bloody  froth 
issues  from  the  mouth. 

This  condition  is  I'apidly  succeeded  by  a  series  of  c/onic 
Kl»((sinii  in  Avhich  all  the;  musch'^  are  thi'own  into  violent  con- 
tractions, causing  (pii(!k  jei'king  movements  of  the  limbs  and 
head.  In  severe  eases  the  woman  may  be  thrown  into  a  p(jsi- 
tion  of  opisthotonos. 

f^'o;/.sc/o?,'v//f.s'.s'  is  lost  (hiring  the  atta.'k  and  tlie  ])atient 
usually  remains  in  a  <H)n(htion  of  coma,  breathing  stertorously, 
for  some  time  after. 

The  dnnitioii  of  the  fit  is  sehlom  longer  than  a  minute, 
while  the  coma  lasts  a  variable  time,  from  a  few  minutes  to 


190  PATHOLOGY  OF  PRIX.' NANCY. 

several  hours.  The  pjiro.wsnis  are  repeated  at  varviufx  inter- 
vals, in  whicli  tlie  j)atieiit  may  regain  consciousness.  In  some 
eases  tiie  patient  remains  in  a  condition  ot'eoma,  witii  or  with- 
out restlessness.  ISoinetinies  restlessness  precedes  aiiotli.  r 
|)aroxysni.  As  many  as  100  lits  have  been  counted  in  one 
case. 

Course  and  Terminations. 

Kelamj)sia  ends  in  recovery  or  death  in  from  thirty-six  to 
i'ortv-eitirht  hours. 

Death  mav  occur  from  o'dema  of  the  hrain,  of  the  lunjrs  or 
of  the  larynx,  asphyxia,  exhaustion,  or  heart-failure.  An 
overwhelming  acciunidation  of  the  tox'inx  in  the  system  iniiv 
cause  the  conui  to  j^row  deeper  and  deej)er,  with  or  without 
the  cessaticm  of  fits.  Not  infre(juently  the  temj)eratin<' 
steadily   rises,  and   the  ])atient  dies  with   hyper|)yrexia. 

Recovery  takes  place  in  about  two-thirds  of  all  cases  luidcr 
proj)er  treatment.  'I'he  fits  cease,  the  secretion  of  the  lu'iiic 
increases,  and  the  cctma  fades  gradually,  tliou<j:h  mental  con- 
fusion often  persists  for  some  time.  The  bowels  and  skin 
bt'come  active.      In  some  cases  a  condition  of  puerperal  ii 


sanity  mav  complicate  the  reeoverv  ;    but  when   it  occurs  if 
is  generally  mild  and  j)asses  off  in  a  few  days. 


Etiology. 

While  we  do  not  know  the  cause  of  eclampsia,  the  })resent 
view  most  generally  accepted  is  that  it  is  the  result  of  a 
toxaemia,  originating  in  the  bodies  of  the  mother  and  of  the 
fo'tus.  The  urine  of  a  healthy  individual  is  highly  charged 
with  toxic  materials.  Bou(;hard  has  isolated  from  the  urine 
two  substances  which  produce  convulsions,  and  one  whicli 
produces  coma.  The  urine  of  the  albumimiric  patient  has 
been  ])roved  to  be  nuich  less  toxic  than  in  the  normal  state  ; 
while  the  urine  of  the  eclamptic  is  scarcely  toxic  at  all. 

In  the  eclamptic  there  is  a  diminution  of  the  urinary 
secretion  ;  combined  with  this  is  an  absence  of  toxicity  of  the 
urine  and  an  arrest  of  elimination  of  the  toxins.  C'oincidinu' 
with  the  disappearance  of  the  toxicity  of  the  urine  there  are  an 
arrest  of  elimination  of  and  an  accumulation  of  toxins  in  the 


PATIIOLOdlCM,   AyATOMX  OF  ECLAMPSIA.  191 

1)1(1. »(1.  rimt  tlic  foxiiis  arc  retained  in  (lie  hhiod  lias  heeii 
nr.»v«'(|  l)y  an  exainiiiaiioii  of  tlie  l»l(>(Ml-.-.ei'iini  of  e<'lain|)tics. 
It  has  l)een  fonnd  that  in  those  oases  tlie  toxicity  of  the  hh)od- 
siiiini  is  in  inverse  proportion  to  th<'  toxicity  of  the  urine. 

As  to  the  formation  of  these  toxins  l)nt  litth-  is  known.  It 
is  -iippi)S(!d  by  some  that  they  originate  chielly  from  the  pres- 
ence of   the    fetus    in    tiie    uterus  ;  hut    the   most    generally 

;i |)ti'd  vi(i\v  is  tiiat  they  originate   from   the  decomposition 

(if  lood  within  the  bowel.  The  liver  probably  |)lays  an  iin- 
|)  iriaiit  part  in  the  destru(!tiou  of  the  toxins,  while  the  kid- 
iirxs  and  skin  are  chari:;e(l  with   tlieir  elimination. 

It  is  a  welbknown  fact  that  the  pregnant  wotnan  rarely  ex- 
cntes  a  normil  amount  of  urea.  Urea  is  the  most  jjowcrfid 
(liiu'etic  known,  and  it  is  probable  that  its  function  is  to 
sli;iiidate  the  kidneys  to  the  elimination  of  the  toxins. 
I  leiice  wiien  the  urea  is  diminished  the  kidneys  are  (K'jU'ixed 
i)f  rheir  stimulus  to  th(^  excretion  of  these  jioisons. 

The  elfect  of  tin;  elforts  of  the  liver  and  the  kidneys  to 
break  up  and  eliminate  the  toxins  is  to  brin^  about  certain 
chanu^es  in  their  structure  which  exj)lain  the  presence  of 
albumin,  as  well  as  of  leu(;in    and   tyrosin,   in   the   urine. 

Pathological  Anatomy  of  Eclampsia. 

The  kidneys  :  In  most  cases  in  which  necropsies  have  permit- 
ted the  examination  of  the  kidneys,  these  oi'gans  jircsented 
ma(n*oscopic  evidences  of  cither  acute  or  chronic  nephritis, 
fii  some  cases  the  kidu(!ys  have  appeared  |)erfectly  healthy. 
But  in  all  cases  in  which  the  kidneys  ha\'e  been  microscopically 
cxamiiied,  certain  chano^es  in  the  structure  have  been  found 
\vlii(!h  are  not  those  of  inflammation,  but  I'ather  (»f  deo('nei'a- 
tioii,  and  very  similar  to  those  changes  associated  with  blood- 
poisoning. 

Phis  ihyencrdflo)}  seems  to  he  of  a  colloid  nature,  and  is 
ii>ually  most  marked  in  the  epithelial  cells  of  the  tubules  of 
th(!  cortex.  To  the  naked  eye,  kidneys  which  have  under- 
i,^oiie  this  degeneration  have  very  much  the  ap])earance  of 
p:u'enchymatous  ne])hritis,  and  it  is  only  by  means  of  the 
iiiieroscope  that  the  true  character  of  the  change  present  can 
be  made  out. 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


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102  rATiioiJxiY  or  vregnascy. 

Tims  ill  ('('laiiij)sia  the  Ic-idii  prcsciit  in  tlic  kidneys  is  iiDt 
ii(ij)liritis,  but  :iii  acute  (lenciieratioii  due  to  toxins  in  tin-  Mooil. 

The  liver:  I  I(iuorriiau;es  into  the  siiUstaiiee  of  tlie  liver  aii.' 
the  most  marke(l  ehaiiu'c  t(»  he  noted  in  these  eases.  'I'hrv 
oeenr  as  dark-red  stains  or  hlotehes,  and  may  he  very  (  \- 
teiisive  ;  or  so  sliu'iit  as  only  to  he  revealed  hy  the  microsen|ic. 
JJetween  the  sites  of  the  hemorrhau'es  the  liver-e(ll>  >li(i\v 
either  fatty  ile<reneration  or  actual  necrosis.  These  chaiitji  > 
can   onlv   re-iilr   iVom   severe  c(  ntaiiiination   of  the   hlood. 

'J'lie  spleen  presents,  as  a  rule,  veiy  much  the  same  chaiiurs 
as  those   fmnd    in    the   liver. 

'I'he  lungs  and  brain  u>i!ally  show  certain  changes  uliii  h 
prohahly  residt  chieHy  iVom  the  eonviilhioiis. 

Diagnosis. 

Eclampsia  has  to  he  distintiuished  from  coir  idsioiis  due  to 
(?pilej)sy,  hysteria,  and  oriranic  hrain  disease.  The  distiiietinii 
may  he  made  by  an  examination  of  the  urine. 

Prognosis  of  Eclampsia. 

Maternal  mc/rtality  is  ahoiit  ''^0  per  cent.,  wliile  tlie  fn  tal 
mortality  is  ahoiit  oO  j)er  cent.  The  earlier  in  pret;naney  tlie 
eclamj)ti('  condition  occurs  tli"   worse  is  the  proi»;no>is. 

Pro<2;nosis  is  favorable  w  hen  : 

The  attacks  are  infre(|ueiit  and  mild  ; 

The  ])atient  reuains  consciousness  hetween  the  attacks  ; 

Tlie  skin,  howels,  and  kidneys  can  he  stimulate(l  t(»  func- 
tionate  fi-eely. 

Proonosis  is  unfavorable  when  : 

riie  attacks  hecome  j)rou;ressively  more  severe  in  spite  'il 
treatment  ; 

The  urine  is  completely  suppressed,  and  j)iir<ration  eamint 
he  induced. 

Treatment. 

The  prophylactic  treatment  of  eclampsia  consists  in  tlie 
fr(>(|uent  examination  of  tlu^  urine,  with  special  retrard  to  the 
(piantity  secreted,  the  j)ercenta*re  of  urea  and  of  aihuniin, 
and  the  presence  and  character  of  sediment. 


J 


772^.  1  TMI'jy  T  OF  I A  'L  A  MPSIA. 


193 


The  hoicrfs  jiinl  shin  slioiihl  he  kc))t  active  hv  the  internal 
aihl  external  use  of  water,  and  mild  laxatives  shonld  be 
ciiiployed   rcuiilarly  it'  n'(|uii'('d. 

The  patient  should  he  ordered  a  reailily  oxidized  and  non- 
(iiDstipating  diet,  and  outdoor  exercise  in  moderation,  and 
(lii-eeted  to  avoid   i'.\j)Osure  to  cold  and  dampness. 

Medical  treatment:  Shonld  the  urea  present  in  the  urine 
t';i!l  to  1.5  per  cent.,  then  treatnicnt  shonld  he  inauixurated,  as 
till-  indicates  renal  inade<juacv. 

The  iiilr()(/('iioiis  diti  should  he  reduced  hy  placinir  tlu; 
jiii'iient  on  a  diet  of  milk,  lish,  and  white  meats.  Klimination 
of  t!ie  toxins  hy  stinudatin*;::  the  action  of  the  bowels,  skin, 
,111(1  kidnevs  is  the  ohieet  of  treatment.  This  ohiect  can  be 
obtained  by  the  re<;ular  use  of  a  pill  of  aloes  and  coK)cynth, 
ur.  V.  at  bedtime,  warm  baths  two  oi'  three  times  a  week,  and 
till'  free  use  of  di'inkin<:;-watei'.  The  occasional  employment 
of  a  dose  consistini>'  of  calomel  and  soda,  (7^7  gr.  x,  will  be 
fdimd   to  stimidate  the  action  of  the  liver. 

When  this  treatment  fails  to  improve  matters,  the  patient 
should  he  put  to  bed,  and  the  diet  limited  to  //////;  as  far  ;is 
|)its>ii)l(>.  The  eliminative  treatment  already  sufrgested  may  be 
iviiiforced  hy  the  daily  lavage  of  the  <'olon  with  at  least  two 
iiiillons  of  noiMual  salt  solution  at  a  temperature  ot"  100°  F. 
Till'  pill  of  aloes  and  colocynth  may  he  replaced  by  Epsom 
or  Hochelle  salts   in  these  more  serious  cases. 

The  kidneys  being  already  overtaxed,  the  eni})loyi^ient  of 
sliinulating  diuretics  should   be  a\<iided. 

During  the  eclamptic  attack  the  following  scheme  of  treat- 
iiieiit  offers  the  best  chance  of  success  in  the  author's  (ij»inion  : 
I>iu'ing  the  convulsion  administer  chloroform,  and  also  when- 
ever for  any  reason  the  patient  is  to  be  disturbed,  shoidd  it  be 
fMimd  that  such  disturbance  tends  to  ]>recipitat(^  a  convulsion. 
Then  inject  hypodernneally  ext.  veratr.  viridis  (ITlxv)  and 
irive  an  enema  containing  chloral  hydrate  (.^j  in  four  oinices 
nt' water),  and  place  two  drops  of  croton  oil  on  the  hack  of  the 
tengue.  Have  the  patient's  clothing  entirely  removed,  and 
envelop  her  body  in  blaid<ets  wrung  out  of  hot  wat<'r,  covering 
the>e  with  several  dry  ones.  Then  inject  into  the  colon  by 
means  of  a  large-sized  catheter  attached  to  a  fountain-syringe 
several  ([uarts  of  warm  saline  solution.  Where  possible  a 
13— Obst. 


194  PATHOLoar  OF  ruEaxAycy. 

pint  or  more  of  sterile  saline  solution  should  also  l>e  inject (  I 
under  the  breasts,  using  a  large  exploratory  needle  for  tins 
purp;)sc. 

Should  the  convulsions  recur  and  the  j)atient  be  a  fu!i- 
bloodcd,  strong  woman,  a  pint  or  more  of  l)l()od  may  Lm 
drawn  by  opening  one  or  more  of  the  large  veins  of  the  arii. 
The  veratrum,  in  TTLv  doses,  may  be  injected  at  short  inter\;il^ 
till  the  pulse  is  reduced  to  70  ])er  minute.  The  chloral  cnena 
should  be  repeated  every  four  hours,  ])rovided  the  conditi  .11 
of  the  pulse  is  satisfactory.  As  soon  as  the  patient  can  swallo"  , 
dessertspoonful  doses  of  a  conct  utrated  solution  of  i^psoiu 
salt  may  be  administered  every  fifteen  minutes  till  the  bow'  Is 
are  acting  freely.  The  hot  ])a(!ks  should  be  renewed  sut- 
ficiently  often  to  keep  up  free  dia})hore>is. 

The  obstetrical  treatment :  When  should  ])regnancy  be  ti  1- 
minuted  in  those  cases  in  which  eclampsia  i<  thrcateiK  il  ? 
When,  in  spite  of  active  treatment,  the  })atient's  conditi  11 
gets  steadily  worse,  or  where  improvement  is  oidy  trau>i(  nt 
and  relapses  occur,  the  only  safe  course  is  to  terminate  the 
pregnancy. 

When  eclampsia  occurs  during  parturition  interfereiK c 
with  the  progress  of  labor  should  be  avoided  until  the  (k 
is  fairly  well  dilated.  Accouchement  force  is  to  be  cdii- 
demned,  except  in  very  rare  instances.  The  convulsions  mii~t 
first  be  combated,  and  as  a  rule  labor  comes  on  spontane(.Mi-l\ . 
It  maybe  terminated  by  forceps  in  order  to  j)revent  its  undnr 
prolongation,  as  soon  as  the  os  is  moderately  di'ated,  the 
patient  always  being  deeply  anjesthctized  for  this  pii'-oose. 

The  after-treatment  consists  in  keeping  uj)  free  action  •! 
the  emunctories.  Daily  doses  of  Epsom  salt  should  be  givrii. 
The  patient  should  be  encouraged  to  drink  large  (juantities  ul' 
cream  of  tartar  water,  oj  to  the  pint.  The  diet  should  Kc 
limited  to  milk  until  the  kidney  condition  has  improMd. 
Heart  tonics  may  be  required,  and  none  is  better  than  str\  ( li- 
nine  in  full  doses. 

ABORTION  AND    PREMATURE  LABOR. 

Definition:  Abortion  is  the  term  used  to  denote  the  exjtiil- 
sion  of  the  ovum  up  to  the  end  of  the  third  month  of  i)icg- 


SYMPTOMS  OF  AliORTTOX. 


195 


nancv.  Premafinr  Uihor  ,-i<j:;nit'u's  tlie  hirth  of  a  vial)le  fd'tus  ; 
w  liile  the  term  mmmrrUirji  is  usually  ai)pli('(l  to  tlio  (•xj)ulsi(>n 
it  the  ovum  hetweeii  the  fourth  aud  sixth  months  ol"  prcj^- 
nanry. 

Frequency:  It  is  iinpossii)le  to  estimate  <'orr(>ctly  the  fre- 
(jiienoy  of  abortion  ;  hut  it  is  ])rol)al)le  that  the  ]>r(»|)ortion  of 
ahortions  is  about  one  in  every  three  or  four  pregnancies. 


Symptoms. 

The  cardinal  symptoms  of  abortion  are,  )Hi'n\,  Ji(iiion'}i(i(/i\ 
ami  the  expulsion  of  tlu;  ovinn.  The  pain  is  due  to  uterine 
(untraetions ;  an<l  the  hemorrha<i:e  results  from  the  separation 
(if  the  ovum  from  its  uterine  attachments. 

Ill  some  cases  the  /icmon-lKif/c  is  the  Ji'rsf  si/uijifoiii,  the  |»ain 
l'(»llo\vin<x  after  the  ovum  has  been  converted  into  a  foi'citiu 
hody  by  the  blood  having  caused  a  separation  of  the  mem- 
hnmes  from  the  decidua. 

In  other  cases  the  j)ainfi  prfccdr  flie  licmori'hiK/c ;  in  this 
iii-tance  the  abortion  is  more  ])rolonged.  as  a  result  of  the 
slnw  separation  of  the  membranes.  It  is  in  this  class  of"  casi's 
that  ])reventive  treatment  is  more  lil<ely  to  be  successful. 

Abortion  may  take  place  suddenly  ;  or  it  may  last  over 
several  days. 

Abortion  occurring  at  or  before  the  eighth  week  partakes 
(if  tiie  character  f>f  a  painful  and  rather  ])rofuse  menstruation. 
Siicli  it  is  often  supposed  to  be  by  the  patient.  In  some  cases 
tlic  uterine  colic  may  be  so  severe  as  to  cause  V(»miting  or  nei-- 
viuis  eiiills ;  the  o\'i  ni  usually  passes  unnoticed  with  blood- 
clnts.  On  bimanual  examination  the  uterus  will  be  foui.d 
enlarged  and  the  os  more  or  less  patulous.  When  the  abor- 
tinii  is  not  complete  fragments  of  the  ovum  may  be  I'elt  vithin 
the  cervix. 

At  the  third  month,  which  is  the  most  common  period  for 
ahtirtion,  the  process  generally  occurs  in  two  stages :  first,  the 
exjMilsion  of  the  fo'tus  ;  and  second,  the  expulsicm  of  the 
n(n\  ly  formed  placenta  and  membranes.  The  ])rocess  is  more 
pfulonged  and  more  painful  than  in  the  earlier  months.  In 
)iimp  cijf<es,  especially  when  the  fietus  has  been  dea<l  for  some 
time,  the  placenta  and  membranes  may  soon  follow  its  expul- 


196 


PATHOLOGY  OF  PREOXANCY. 


sioii.  Should  the  placenta  remain  adherent,  the  cervix  niav 
close  a^ain,  though  the  pains  and  hemorrhage  may  contimi  . 
As  the  placenta  is  softer  and  more  attached  to  the  uterus  tluiu 
it  is  later,  it  is  more  a})t  to  come  away  ])ieceme;d  ;  hence  poi- 
tions  mav  he  retained  for  davs,  weeks,  or  even  months,  atid 
give  rise  to  a  varied  train  of  symptoms. 

Abortion  after  the  fourth  month  gives  rise  to  the  clinical 
phenomena  of  a  Uiiniature  labor. 

Pathology  of  Abortion. 

As  the  result  of  uterine  contractions,  or  from  dt^generatinn 
of  the  vessels,  blood  is  effused  from  the  ru))tui'e(l  vessels  iiitd 
the  decidua  vera,  and  forces  its  wav  between  the  deci<lua  and 
chorion,  stripping  off  the  ovum,  which  is  then  expelle<]  eutiir. 
If  the  ovum  be  lioated  in  water,  it  presents  very  nmch  the 
aj)j)earance  of  a  chestnut-burr. 

Occasionally  the  decidua  is  cast  off  entire  along  with  the 
ovum,  which  it  completely  envel(»ps. 

Occasionally  also  blood  is  extravasated  into  the  membranes, 
at  intervals.  This  coagulates  in  strata,  and  leads  to  the  for- 
mation of  what  is  known  as  a  blood-mole. 

Jn  some  cases  the  abortion  may  not  be  completed  for  some 
time,  and  the  coloring-matter  of  the  etVused  blood  may  Ix- 
al)S()rl)ed,  while  the  strata  undergo  ])artial  organization  and  a 
fleshy  mole  residts.  This  may  form  a  connection  with  the 
uterine  wall,  and  be  retained  indetinitelv. 

In  those  cases  in  which  ])ortions  of  placenta  are  retained 
these  masses  may  form  polypi,  remaining  in  the  uterus  f'ui' 
weeks  or  months,  causing  a  fetid  discharge  and  an  elevatida 
of  temperature. 

Etiology. 

The  causes  of  abortion  may  be  divided  into  those  of  patcfiKtl, 
of  maternal,  or  of  fatal  origin. 

Paternal:  Syphilis  is  jirobably  the  most  common  patenuil 
influence  in  causin<r  abortion.  Other  causes  which  nun  ho 
mentioned  under  this  heading  are  alcoholism,  debility,  tuber- 
culosis, lead-poisoning,  advanced  age,  and  excessive  venery. 

Maternal:  General:  Similar  causes  to  those  mentioned  in 
the  father  act  in  the  mother. 


JJIA ayuSl.S   Oh    Alio II TIOX 


197 


Acnfr  (1 11(1  rfii'oiiic  ifisr(i.-^(s  cmiiso  abortion  Ia'  excess  of  tem- 
]M  iMture,  or  l)y  hlood-elianu'es,  oi-  by  j',ro<liieiii<;  alterations  in 
till'  placenta.  'I'raiinia(i>ni  and  severe  emotional  distiirliancis 
iiiav  j)ro(iuce  aWoi'tion.  ( 'eiMain  diai^s,  a>  (piinine,  savin,  erixot, 
Mini  a  host  of  others,  are  said  to  canse  abortion  ;  hnt  it  is 
(l.iihtfid  if  this  is  the  case  when  the  nterns  is  in  a  normal 
(Miidition. 

Li)C((l :  J)isj)lacei!ients  of  the  nterns,  pelvic  inflammations 
(.1  adhesions,  cervical  lacerations,  endometritis,  nieti-itis,  filiro- 
iiivomata,  and  abnormal  development  of  the  nti'nis  may  be 
mentioned  as  conditions  which  predispose  to  abortion. 

fhore  are  women  who  abort  constantly  in  whom  no  reasoii- 
;il'le  cause  can  be  tbund  ;  to  this  condition  the  term  '''  hdhihatl 
iih'iiilnii  "  is  applied. 

Foetal:  Svj)hilis,  which  acts  by  j)rodnciniji:  chano;es  in  the 
ovum  or  in  the  placenta,  leadinir  to  the  death  of  the  lietus,  is 
jn'obablv  the  n)ost  common  lo'tal  cause  of  al)oi'tion. 

DeiTcneration  of  the  chorion,  hydramnios,  and  vicious  inser- 
tion of  the  placenta  fre(piently  result  in  abortion. 


Diagnosis. 

In  caocs  of  suspected  abortion  it  is  necessary  to  detennino 
tlie  existence  of  |)i'en;ii;incy.  The  abortion  may  be  flirr(ifr)n(l ; 
(inrifdh/c;  or  wholly,  or  |>ai'tially  arconijt/is/Kd. 

Threatened  abortion:  If  the  patient  h:is  been  exposed  to 
the  j)o-sibility  of  impreu'iiation  and  the  menses  jiave  be<'n  suj)- 
|»i-cs>ed  ;  if  a  hemorrhage  from  the  uteiMis  occur,  associated 
with  more  or  less  pain  ;  then  it  is  j)robable  that  an  abortion  is 
thi'catened. 

nysmenorrh'ca  may  be  mistaken  for  ifn|)endinu^  abortion  ; 
hut  in  this  case  the  cervix  is  clos(>d  and  firm  to  the  feel. 
Ilcinorrhau'c,  associated  with  the  j)resence  of  a  stiff  jto/i/jtoiil 
I'ltiinr  ill  the  uterus,  may  simulate  the  condition  of  tlir<'at- 
cin'd  abortion  very  closely  ;  but  a  careful  local  (examination 
w  ill  uenerally  establish  the  nature  of  the  condition  ])resent. 

Inevitable  abortion:  When  the  membranes  have  ruptured,  or 
tlie  fetus  is  dead,  or  wluMi  any  fetal  part  is  enpi^ed  in  the  cer- 
vix, the  abortion  may  be  said  to  be  iiirvifdh/c.  Cases  have 
iHciirred  in  which  large  portions  of  decidua  have  escaped  from 


15J8 


VATllOUHiY   OF  I'RIJuyAyCY. 


tlio  uterus,  associated  witli  eouslderable  lieinorrlia^e,  nud  vr  i 
have    ;tfter\\ar<l    ^(Uieou   to  full    tenu.      Agaiu    the  os  ui;i 
ojK.'U  sullicieiitly  lo  admit  the  tinker,  yet  close  atjjaiu,  ;iud  tli 
prcj^iiaucy  coutiuue.       It    is,  theretbre,  souietiiues  a  dilhcu 
matter  to  say  that  an  abortion  is  "  inevitable." 

Complete,  or  partial,  abortion  :  It  is  imptirtaut  always  to  <!• 
termine  whether  a  j)art  of,  or  the  whole  uterine  contents  ha.  • 
been  expelled.  To  make  a  dia<i;nosis,  everything  (liseh;n'n(  ,1 
from  the  uterus  nnist  be  carefully  examined  ;  when  anv  doiil  ; 
I'cmains  a  di<;ital  exploration  of  the  uterine  (;avity  must  1h 
made;  when  anytliing  is  retained,  the  cervix  usually  remaii  - 
j)atulous  so  that  the  finger  can  be  inserted  without  nuicli  dil- 
ticultv. 

In  cases  ol"  complete  abortion  in  the  first  two  months  ot' 
pregnancy  there  is  functionally  no  lochial  discharge.  ShouM 
the  liemorrhage  continue  it  is  probable  that  [)ortions  of  the 
decidua  have  been  retained. 

In  incomplete  abortions  at  the  tiiird  month,  or  later,  tin' 
lochial  discharge  remains  free  and  bloody,  instead  (»f  gi'adualK 
subsiding,  as  it  should  when  the  uterus  has  been  emptied  aiil 
is  involuting  properly. 

Prognosis. 

The  prognosis  of  abortion  dejiends  upon  the  treatment. 

If  the  uterus  has  been  carefully  emptied  uiuh'r  aseptic  pre- 
cautions, then  the  mortality  from  abortion  should  be  ////. 

Retained  masses  of  (h'cidiia  or  of  )>]acenta  are  followed  bv 
decomposition  of  these  sid)stanei's  in  iitero,  and  acute  or 
ciironic  septic  infectio!i  is  the  result. 

Hemorrhage  very  rarely  leads  to  a  fatal  result  in  eases  nt' 
abortion. 

When  neglected,  abortion  may  be  the  starting-point  of  vaii- 
ous  uterine  diseases,  as  subinvolution,  metritis,  etc.,  whidi 
may  lead  to  invalidism. 


Treatment  of  Abortion. 

Prophylactic  :  When  any  of  the  conditions  are  present  whicli 
may  tend  to  premature  expulsion  of  the  ovum,  all  precaution- 


TllEATMEST   OF  AnoRTinN.  li><> 

I  , list  1)C  takon  to  provont  siu-Ii  an  accident.  Ai)i)r<)|)riatc 
--tcniic  treatment  should  he  imdertakeii  wlien  indicated,  and 
;  the  same  time  the  patient  slionhl  he  instrncted  to  (fhsei  ve 
-jicciid  precantions,  snch  as  the  avoiihmce  of  o\'ei-e.\ertion 
\<v  Hfting  or  rcachini:',  |)artienhirly  at  the  menstrual  periods. 
I  he  nse  of  stronj:;  pnr<iatives  should  l)e  avoided.  At  <'acli 
iniii-irnal  epoch  the  patient  should  ri-main  in  hed  for  several 
(livs.  Ahnormal  uterine  conditions,  such  as  displacements, 
metritis,  and  lacerations  of  cervix,  should  receive  apjtropriale 
livatnient.  Sexual  intercourse  should  he  avoided,  esj)ecially 
;ii  or  ahout  th(!  menstrual  ej»ochs. 

Threatened  abortion  :  The  main  princi|)le  of  treatnient  is  to 
>triire  for  the  patient  ahsolute  I'cst,  mental  and  physical. 
This  is  obtained  hy  puttini:'  her  to  bed,  in  a  cool,  darkened 
ii II iin,  where  she  can  he  ke|)t  in  ahsolute  (juietne.ss ;  and  hy 
till'  free   use;  of  opium,  hro:  lide,  and   chloral. 

(J|)ium  is  hest  admini,->tered  hy  the  rectum.  A  supjxisitory 
cniitaining  ()j)inm,  gr.  ss,  should  he  gently  inserted  every  eight 
ii.iiu's,  or  at  least  sunieiently  often  to  kecj)  the  patient  well 
under  the  in(luence  of  the  drug.  At  tiie  same  time  a  ndxture 
(•(intnining  sodium  hromide,  gr.  xxx,  and  chloral  hydrate,  gr. 
x\ ,  Uiay  he  given  three  times  daily.  Many  |)i-efer  the  lluid 
extract  of  vihurnum  prunif(»lium  in  drachm  doses,  t.  i.  d., 
iii-tead  of  the  hromide  and  ciiloral  nuxture. 

Inevitable  abortion  :  'I'wo  methods  of  treatment  are  avail- 
;iMe,  the  cxj)ectant  and  the  active: 

The  expectant  treatment:  Should  tlie  hleeding  he  severe 
hefoi-e  the  OS  is  dilated,  it  must  he  c(»ntrolled  hy  means  of  a 
vnginal  tanijmn  of  sterile  or  iodoform  gauze.  To  apply  va- 
Liiiinl  tamponage  pi'operly  the  ])atient  should  he  ])laced  in  the 
let'i  semiprone  ))osition,  with  the  hi|)s  resting  on  a  ruhher 
>lieet  or  Kelly  jiad  at  the  edge  of  the  hed.  '1  he  vulva  and 
v.iuina  should  then  he  waslied  with  s])irits  of  green  soap  and 
liut  water,  and  tlien  swahhed  with  a  1  :  oOO  formalin  solution. 
It'  the  vulvar  hair  is  long,  it  should  he  clij)ped.  The  only 
iii-truments  recpiired  are  a  Sims  speculum,  a  pair  of  uterine 
rnivej)s,  and  a  |)air  of  scissors,  wliich  may  be  sterilized  wliile 
the  patient  is  being  pre))ared. 

riie  sj)eeulum  is  then  inserted  and  the  perineum   reti'acted 
so  as  to  expose  tlie  cervix  to  view.     A  strip  of  gauze  (sterile 


200 


PATUOiJK'.Y   OF  PIlF.dNASCY. 


or  iodoform),  about  two  indies  wide  and  a  yard  lon<;,  is  then 
seized  ai>ove  hy  means  of  tlie  uterine  forceps  and  |>ael<(il 
lirndy  around  tlie  .ervix.  As  the  j^au/e  is  beinjj:  inserted  tin 
speeulnni  is  gradually  withdrawn.  A  snilieient  (piantity  u\ 
\f\\\\/.v.  siiouhl  be  inti'o(hi(!ed  to  distend  tlie  vagina.  IIm 
patient    is  then   made  eomfoi-tal»l(!,  and  should    remain   in  bed, 

'1\)  facilitate  tlie  emptyiiiu:;  of  the  uterus,  the  lluid  extract  (•! 
eru:ot  may  be  administered  in  hall-drachm  doses  three  tim<  - 
daily.  If  the  uterine  eontraetioiis  are  |)aiiiful,  an  opiate  ma\ 
i)e  combined  with  the  erj^ot.  The  vauiual  tampon  should  l>r 
reniove<l  in  twenty-four  hours,  and  rephuted  by  a  fresh  one  it 
necessary.  A  close  watch  should  be  kept  over  the  }>Htient'> 
temperature.  Often  when  the  first  tamjum  is  removed  tli. 
ovum  comes  with  it,  or  tlu;  cervix  will  be  found  softened  and 
tlu;  OS  sufficiently  dilated  to  permit  the  intn»(hietion  of  the 
finjrcr,  with  which  the  ovum  may  be  extracted.  If  the  o\  iim 
rupture  and  a  |)art  be  rettiiiied  in  the  uterus,  the  woman 
must  1)0  kept  in  bed,  the  eri!;ot  continued,  and  the  vagina 
(hiily  douched  with  a  solution  of  formalin,  1  :  oOO.  In  many 
cases  this  treatment  will  be  sufficient;  but  in  spite  oC  eveiv 
])recaution  the  discliarires  may  become  foul  and  the  tempera- 
ture rise,  in  which  case  the  uterine  cavity  must  be  tlioroui;lily 
curetted. 

Active  treatment :  This  is  the  treatment  to  be  reeomnuMidcfl, 
in  preference  to  the  exj)ectant  plan,  in  the  larixe  )>roportion  <>r 
cases.  The  va<;inal  tampon  may  be  eni])loyed,  as  recommended 
above.  If  at  the  end  of  twenty-four  hours  the  os  is  lu-t 
])atid()us,  the  patient  should  be  antesthetized,  and  the  cer\  i\ 
dilated  with  Il"u:ar's  or  Barnes's  dilators,  and  the  uteiii> 
emptied,  as  recommended  i)elow. 

As  soon  as  the  os  is  sufficiently  dilated  to  permit  the  intrn- 
ducti(;.i  of  the  for(^Hn<>^<>r  the  ovum  should  be  nvept  out  ami 
the  decidua  or  placenta  removed  by  scrapin<>:.  The  forefiniici' 
of  the  rii^ht  hand  is  the  best  instrument  for  tl  s  purpose.  It 
can  be  made  to  reach  all  parts  of  the  uterus,  with  the  assist- 
ance of  the  left  hand  pressing  on  the  fundus  tliroui>h  the 
abdominal  wall.  When  the  secundines  cannot  all  be  removed 
in  this  manner  the  interior  of  the  uterus  may  be  pMitlv 
scraped  with  a  blunt  curette.  In  all  cases,  after  emptyiuir  tlie 
uterus  its  cavity  should  be  thoroughly  douched  with  i>laiii 


MISSED   LABOR.  201 

-toriIi/o(l  wjitor  or  formalin  solution,  ux'd  hot.  l-'or  (his  pur- 
[lose  the  Frits('h-l)o/.('m;ui  uterine  catheter  is  l»y  lar  the  l>e~t 
iiistninient.  The  I*]Mimet  :'iirette  fltn-eps  will  he  loiind  (n  l>e 
;i  verv  valnahle  adjuvant  to  the  etirette  in  reinovini;  shreds 
Iroin  the  uterine  cavity. 

After-treatment  of  abortion:  'I'he  woman  shoidd  hi-  Ue|»t  iu 
hed  for  at  least  a  week  or  ten  days,  the  temperature  should  he 
watched,  and,  ii'  necessary,  a|)|)i't»|>riate  treatment  to  prevent 
die  onset  of  lactation  should  he  ap[)lied. 

Missed  Abortion. 

It  occasionally  happens  that  the  fictus  jierishes,  symptoms 
(il  inipendin;;  alxtrtion  develop  only  to  <lisa|)pear,  and  the 
(ivum  is  retained  in  the  utei'us  for  weeks,  or  e\-eii  months.  'I'o 
ihis  condition  the  term  "  nussed  ahortion"  is  applied.  No 
li'dfiiH  iif  is  indicated,  provided  the  condition  does  not  alTect 
the  (General  health  of  the  patient,  for  sooner  or  later  contrac- 
tidiis  will  occur  and  the  uterus  empty  itself  of  its  contents. 

Premature  Labor  and  Miscarriage. 

The  ])henomena  (tf  i)remature  lahor  are  very  much  tlie 
siunc  as  of  lahor  at  terni,  with  the  exception  that  the  placenta 
i-  more  fre(piently  adherent  to  the  uterine  wall.  When  such 
i<  the  ease  th(^  uterus  must  l)e  entered  and  the  placenta 
stri|)pe(l  off*  and  removed,  after  which  a  hot  uterine  douche 
should  be  given. 

Missed  Labor. 

In  this  condition,  which  is  v(M'y  rare,  the  woman  may 
exhibit  a  few  ineif'ectual  siu:ns  of  labor  at  term  ;  these  disap- 
pear, and  the  ]>roduet  of  conception  is  retained  in  utero  for 
months,  or  even  years.  The  f<etns  in  these  cases  always 
perishes,  and  either  macerates  or  mimimifies.  The  soft  parts 
of  the  fdctus  may  be  absorbed,  and  the  bones  may  l)e  dis- 
cliarired  at  intervals  for  a  lonir  time  afterward,  or  they  may 
find  their  wav  thron<j;'li  the  uterus  into  the  bladder  or  rectum, 
ir  is  a  (/()()(J  r/nirrd/  rn/c  to  induci'  labor  in  all  cases  in  which 
tile  patient  is  known  to  have  gone  two  weeks  beyond  the  nor- 
mal j)eriod  of  pregnancy. 


•J02 


pATUoLodY  OF  rnKasAycY, 


ECTOPIC    GESTATION. 

Definition:  \\'lu'ii  tlic  imj)r('^n;it('(i  ovum  bcconios  attaclicd 
aii<l   develops  (>iit>i<ie   tlie   iitei'iiie    cavity,   the    juc^iianev   i- 
t(  i'liied  ectopic,  or  e.xtra-iiteriiie. 

Frequency:  Ectopic  p'statioii  (tceiirs  ])r(»l>al)ly  al)out  oii.  < 
ill   o(K)  cases  of  |»re^iiaiicy. 

Varieties:  'I  here  are  //wee  priiiKiri/  Jonus  of  rcfojtic  (jtsfit- 
ti(jii :  (1)  hihiil ;  ['!)  nrtii-ifiii  ;  and  (.'i)  dhdoviiiid/. 

Many  authorities  classily  the  \arious  terminations  of  tlie>( 
primary  forms  of  ectopic  gestation  as  .scccnidfiri/  fonns^  earli 
heiiiij:  (K'xi^nated  accordiiio'  to  tlie  location  of  the  disj)lae((i 
ovum.  Tlu!  term  "secondary"  as  thus  empioyed  simpK 
means  siiffscfjiiciif  to  nijifm-r  or  dis])laeement. 

AV'hilo  |)riniary  ovarian  and  alxlominal  ]>ref2iiaiicies  (|m 
occur,  they  are  iindoiihtedly  extremely  rare,  and  are  dilliciih 
of  ahsol'.ite  demonstration  ]  as  a  general  rule,  ectoj)ic  gestation- 
are  filfxl/. 

Tubal  pregnancies  are  classified  according  to  the  site  of  the 
attachment  of  the  ovum,  .'is: 

(1)  / iifcrsf/fia/  when  the  o\'um  develops  in  that  ))'>rtion  ol' 
the  tnhe  which  j)asscs  through  the  Mall  of  the  utei'U, ,  or  in  a 
diverticulum  '>^'  this  ])ortion  of"  the  tiihe. 

(2)  True  tiifxi/,  or  amj)ullar,  when  the  ovum  develops  in 
the  free  portion  of  the  tube. 

(.'))  Iiif'ini(li/)ii/(ir  when  the  ovum  develops  in  the  infiindili- 
uliim  of  the  tube,  and  j)revents  the  closure  of  the  td)doniinal 
ostium.     Cases  of  this  varietv  are  also  termed  fitbo-ordrtcii. 


Terminations  of  Ectopic  Gestation. 

Interstitial  pregnancies  usually  terminate  al)out  the  thinl 
month  by  rupture  into  tlie  j)eritoneal  sac.  The  patient  g(  ii- 
erallv  succumhs  to  hemorrhage  and  slioek.  Ivuptni'e  into  tin- 
uterine  cavity,  with  ex])ulsion  of  the  fcetiis  through  the  c(>rvi.\. 
is  possible,  as  is  also  rupture  into  the  base  of  the  broad  liga- 
ments. 

True  tubal  pregnancies  terminate  by  rupture  cither  (<()  u\)- 
ward  into  the  abdominal  cavity,  or  (l>)  downward  ')etwc(  n 
the  layers  of  the  broad  ligament.     When  the  rupture  occurs 


TKIiMIXATI(L\S  OF  hCTOl'lC  (U-.STATION. 


20;] 


lih  the  ahtloininal  ravUtj  tlu>  licinonliM^o  Is  usually  severe, 
iiml  may  l)e  fatal  in  from  sixteen  hours  to  three  or  four  days. 
When  rn[)tnre  occurs  early  and  the  heniorrhap'  is  not  severe, 
tiie  fu'tus  ujav  bo  ahsorlied,  as  the  enihrvonic;  sac;  usually 
I  iptures  at  the  sanie  time  as  the  tuhe. 

When  the  ruj»ture  occurs  (loinniuird,  between  the  layers  ol' 
till'  broad  li»;ainent,  the  ovum  may  perish  and  all  trace  ol"  it 
(li*ap|tear,  while;  the  blood  eit'used  may  be  i-etained,  Ibrmini;  a 
p  'Ivic  hiemato(;el(;.  The  ovum  may  develop  ibi'  a  time,  ami 
then  burst  into  the  peritoneal  cavity,  or  continue  to  full  term 
liv  slrii)pin<^  the;  peritoneum  I'rom  thi'  pelvic  wall  as  it  en- 
l;u'ixcs.  In  either  ease  the  ovum  develops  tor  a  tim<'  and 
then  perishes,  and  is  either  absorbed  or  macerated,  when  it 
iiKiv  ulcerate  throu<^h  i'  ^o  the  bow(;l,  bladder,  or  vagina,  and 
('-(■ape. 

In  still  other  cases  the  gestation-sac  may  undergo  putrel'ac- 
tinii  from  access  of  bacteria  from  tlu;  bowel,  and  be  converted 
iiiio  a  broad  ligament  ab'.cess,  which  may  rupture  into  the 
jH'ritoneal  cavity,  or  into  the  bladder,  rectum,  or  vagina.  In 
other  cases  the  f(etus  aft(  r  death  mav  be  conveiMed  into  a 
liiliopicdion  or  may  be  mummilied,  and  thus  remain  for 
ycai's. 

Infundibular  pregnancies  may  either  rupture  into  the  perito- 
neal cavity  or  develop  to  full  term. 

Ovarian  pregnancies  may  terminate  by  rupture  of  the  sac 
and  profuse  hemorrhage;  or  arrest  of  (h'velopment  may 
occur  at  an  early  period  and  the  sac  remain  a  cvstic  tumor. 
Advance  to  ftdl  term  is  j)ossible,  but  not  ))robable. 

Abdominal  pregnancies  may  advance  to  full  term  ;  or  the 
sue  may  rupture  early,  and  the  fetus  be  either  absorbed  or 
mummify. 

Tubal  abortion :  This  term  is  aj)plied  to  a  certain  rare  con- 
dition in  which  blood  is  effused  into  the  ovum,  destroying  it 
and  its  attachments  to  the  tube-walls.  The  ovum  may  re- 
main as  a  inlxil  mo/c,  forming  a  solid  tumor  of  the  tube  ;  or  it 
may  esca))e  with  the  blood  from  the  timbriated  extremity  of 
the  tube  into  the  abdominal  cavity. 


204 


PATIIOLOUY  OF  rEKGNAiWY. 

Etiology  of  Ectopic  Gestation. 


As  has  been  stati'd,  tlio  ovum  usually  Ix'conu's  iuipro^- 
natcd  while  still  in  the  l''all(»j)ian  tuhc.  1 1'  the  tube  is  in 
a  iiornial  coiKliliou.  tlio  iinprcjiiiatcd  oviiiu  is  uiovcd  alou.; 
il  iiniil  it  liuds  its  rcstiun-jdacc  iu  the  titcriuc  cavitv.  It  i- 
th(!i"etoro  pi'ohahlc  thai  the  most  important  liictor  iu  pfodiR-iiiM 
eciojtiir  *iC'statiou  is  some  abnormal  condition  of  the  tubes. 

Sueh  abnormal  conditions  may  arise  either  from  liiflnut- 
i.Ktlioii  of  the  tissues  of  the  tubes  or  from  |»arametrilir 
exudations,  which  lea<l  to  their  constriction  or  desiructiini. 
Jld/joniKi/ioiis  of  the  tubes  are  not  iuiVe((Uent,  such  a>  di- 
verticida,  accessory  tubal  canals,  etc.,  and  iiave  been  noticed 
in  connection   with  ectopic  gestation. 

Any  diseased  condition  of  the  mucous  memhranc  of  the 
tubes,  or  any  condition  which  iuterfeivs  with  their  noruKii 
peristalti(^  at^tion,  may  be  said  to  favor  the  (U'veloj)ment  oT 
ectopic  iLj;estation. 

'J'he  coniUtion  is  generally  encountered  iu  women  who 
present  a  history  of  a  protracted  period  of  sterility. 


Pathology  of  Ectopic  Gestation. 

The  uterus:  With  the  establishment  of  prcirnancy  flic 
uterus  begi'is  to  enlarge  ;  (he  enlai'gement  continues  througli- 
out  the  pregnancy,  though  at  a  much  slower  rate  than  is  tlir 
ease  in  iutra-uterine  gestation.  As  a  rule,  this  organ  begin- 
to  involute  when  the  fetus  j)erislies.  A  dccidua  f)rms  in 
all  cases  of  ectopic  gestation,  which  is  <piite  similar  to  tlic 
dccidua  vera  of  normal  pregnancy.  It  is  cast  off  eitlii  r 
eom|»lete  or  in  shreds,  at  the  time  of  the  primary  tub;il 
ru|)ture,  whetlier  the  ovum  ]>erishes  or  not.  'fhe  shredding 
of  the  (Ku'idua  is  invariably  accompanied  with  nietrorrhagin. 
The  de(!i(hia  varies  in  thickness  from  one-eighth  to  one-fourili 
of  an  inch  ;  it  is  sliaggv  on  its  uterine  side,  while  its  imici' 
surface  is  quite  smooth  and  shows  no  trace  of  either  the 
decidiia  serotina  or  rcHexa. 

Changes  in  the  tube  and  ovum:  As  tlie  tube  eidarges  its 
relation  to  surrounding  pai'ts  becomes  greatly  nioditied.  'flic 
first  change  iu  the  tube  is  a  turgesccuce,  (hie  to  in(!rease  in 
size  of  the  vessels,  the  result  of  the  stimulus  of  pregnancy. 


SYMPTOMS   OF  ECTOPIC  GESTATION.  205 

Tho  imiscle-fihrcs  of  the  tube's  walls  tlicn  iiicroase  in  si/.c, 
Imt  later  ali'ttpliy  a-  the  result  of  iniiuite  ruptures  due  to  small 
jicniorrliaiics  into  llieir  >iil»taii<'e.  Tlieii  lollows  tree  develoj)- 
iiu'Ut  ol'  eonueetive  tissue,  w  liieli  replaces  in  threat  part  the 
iiiiisele-Hhres.  As  the  o\  inn  eiilarii'o  the  tnhe-walls  heconio 
iliinned  out,  the  thiekesi  jtait  Iteinn'  '*t  the  >ite  oi"  the  placental 
;iltachinent,  and  the  thinne>t  <lirectly  oppo.-ite.  ('losnreot' 
the  abdominal  ostium  usually  takes  j)lace  at  the  sixth  or 
-cventh  week  ;  ruptiu'c  ol'  the  tuhe  takes  place  helbi'c  the  end 
of  the  second  month  in  prohahly  two-thirds  of"  the  cases. 

The  tul)i'  ix  iiiorahlc  to  a  limited  decree  until  lixed  hy  peri- 
tonitis. I'^rom  its  increased  wei»:lit  it  tends  to  l"all  helow  its 
iioinial  level,  and  it  mav  he  f'oinid  in  Hoiiulas's  pouch.  As  the 
ovmn  enlarges  the  uterus  is  pushed  to  one  side,  in  some 
ci-es  the  tuhe  remains  closely  attached  t(»  the  uterus,  while  in 
others  it  Ibrms  a  distinct  mass. 

Jn  the  prejj^nant  tuhe  a  da-iiliKi  is  formed  \vhich  is  coni])()sed 
of  the  usual  two  layers,  a  suj)erticial  compact  and  a  spouirv 
lower  layer.  That  j>ortion  ol"  the  <leci(lua  which  is  to  form 
the  maternal  placenta,  and  which  corresponds  to  the  serotina, 
ij,rows  more  rapi<lly  than  that  in  the  rest  oi"  the  tuhe.  A  de- 
cidna  rcHcxa  is  also  formed,  but  it  tends  to  dea-enerate  rapidly, 
and  fi:;ives  rise  to  hemorrha;^cs  vei'y  early  in  the  |)i'eji'nancy. 
These  hemorrhaucs  result  in  inllammatory  changes  which  alter 
the  i^eneral  texture  of  the  mass. 

The  placenta  is  formed  in  the  same  way  as  in  intra-ut<'rine 
gestation,  but  the  lack  of  sj)ace  in  the  tube  results  in  traiima- 
ti-ms  which  alto<2:<>ther  change  it<  charjicter,  converting  it  into 
a  liver-like  mass.  When  the  tube  rujtturcs  the  torn  walls 
nt"  the  tid)e  sprea<l  out,  and  should  the  ovum  siirviNC,  the  pla- 
•  •eiita  forms  attachments  to  neiuhboring'  structures  and  con- 
tinues its  <j^rowth. 

The  amnion  and  chorion  are  oidy  altered  from  their  usual 
<onditi(Uis  by  the  residts  of  trauma  and  sej)sis. 

Symptoms  of  Ectopic  Gestation. 

'i'lu!  phenomena  which  indi  -ate  the  existence  of  ectopic  ires- 
lation  are  :  irrcf/nhir  liniiorrJi(i(/rs  from  the  vagina  accompanied 
with  more  or  Ann  scrcrc  pc/ric  jxt'ni ;  and  the  prci^ehcv  of  a  i)i<tss 
c/u.se  to  and  offni  dssoridfid  trifh  (he  nfenix. 


200  PATHOLOGY  OF  PREGXANCY. 

Tn  a  typical  case  the  ])ationt  has  been  regular  in  menstrua- 
tion for  some  time,  wlien  siie  misses  a  period.  Shortly  atn  i 
this  she  ha.-,  irregular  attacks  of  bleeding,  aceoinpauied  wiili 
sharp,  cutting  pelvic  })ain.  These  symptoms  may  lead  to  tin 
suspicion  of  al)ortion,  which  is  strengthened  by  the  passage 
of  portions  of  decidua.  One  of  these  attacks  may  be  exee>- 
sivelv  severe  and  cause  collapse.  Not  infre(picntly  the.-c 
attacks  are  ac(!omj)anied  by  dysuria  and  rectal  tenesmus. 

The  amount  of  blood  lost  varies  from  a  mere  show  to  :i 
severe  hemorrhage;  with  the  blood  may  be  found  small  shreds 
of  mucosa,  or  even  a  comi)lete  cast  of  the  decidual  lining  of 
the  uterus. 

The  pelvic  pain  is  usually  of  a  sharp,  tearing  character ; 
when  excruciating,  and  accompanied  with  collapse,  it  indicatt  -« 
a  serious  rupture. 

A  vaginal  examination  in  such  a  case  will  reveal  the  pres- 
ence of  a  mass  in  close  ))roxiniity  to  the  uterus,  which  may 
be  found  somewhat  (Milarged.  The  character  of  the  mass  de- 
pends uj)on  the  situation  of  the  ovum  and  whether  it  has  rupi 
ured  or  not.  In  cases  in  which  rupture  has  taken  place  early 
into  the  general  peritoneal  cavity  no  mass  may  be  felt. 

[f  the  first  attack  be  survived,  other  similar  attacks  mav 
follow  and  the  internal  hemorrhages  be  fatal.  Jn  other  oases 
the  effused  blood  may  be  absorbed  after  the  perishing  of  the 
ovum. 

The  ovum  if  it  survive  may  go  on  developing,  in  which  case 
signs  of  pregnancy  will  continue,  an  abdominal  tumor  develop, 
and  finallv  evidences  of  a  livinj;  fa>tus  will  manifest  theni- 
selves.  Such  cases  may  go  on  to  full  term  and  a  spurious 
labor  occur. 

In  other  cases  secondary  rupture  takes  place  at  a  later  ])eritMl 
when  the  patient  usually  dies  of  hemorrhage  or  peritonitis  ;  of 
if  the  patient  survive,  the  foetus  becomes  mummified  or  form- 
a  lithopa}(lion,  being  retained  for  some  time,  and  finally  is  cas: 
out  piecemeal  thropgh  a  fistulous  opening. 

Diagnosis. 

To  make  a  positive  diagnosis  of  ectopic  gestation  previous 
to  rupture  of  the  sac,  while  possible  in  a  large  majority  ol' 


TREATMEXT  OF  ECTOPIC  CESTATIOS.  2()7 

cases,  is  ahvavs  a  niattiT  (»t'  (lilliciiltv.  Tlic  liistorv  of  the 
hiij^ns  of  early  prejiiiancv,  a>s(i<'iatc(l  uitli  airirravati'd  rcllcx 
luTVous  phenomena;  tlie  early  aj)j)earanee  of  sliai'|),  crainj*- 
iike  pelvic  pain  increasing  in  severity,  make  a  diagnosis  pos- 
.';il>le. 

Usually  the  condition  is  not  recognized  until  rupture  has 
taken  place.  At  this  time  the  history  of  delayed  menstrua- 
lioii,  the  occurrence  of  a  paroxysm  of  frightful  pain,  sudden 
(.ilhipse,  and  symptoms  of  internal  hemorrliage  make  the 
diagnosis  very  sim})le. 

A  microscopical  examination  of  the  shreds  contained  in  the 
\aginal  blood  will  reveal  their  (lecidual  chara<'ter,  and  make  a 
(litl'erential  diagnosis  from  al)ortion  ])ossil)le,  as  no  chorionic 
\illi  will  be  found  unless  the  pregnancy  is  intra-uterine. 

In  cases  of  advanced  ectopic  gestation  the  diagnosis  is,  as  a 
\'\\\e,  not  ditiicult.  Owing  to  the  great  displacenuMit  of  con- 
tiguous organs,  abdominal  pain  is  often  excessive.  This  j)ain 
i-  due  in  part  to  j)rcssm(',  and  in  |)art  to  the  development  of" 
jH'ritonitis  of  a  chronic  type. 

Prognosis. 

Ectopic  gestation  is  one  of  the  most  serious  obstetrical  condi- 
tions. If  left  to  nature,  the  mortality  is  over  (K)  per  cent.,  the 
remainder  recovering  by  d(\ath  of  the  ovum  and  absorj)tion 
of  the  consents  of  the  gestation-sac. 

When  treated  by  abdominal  section,  Mirst  states  the  mor- 
tnlity  should  be  alxMit  5  per  cent,  or  lower,  if  the  operator 
sees  the  patient  in  time. 

Treatment. 

As  soon  as  a  diagnosis  of  ectopic  gestation  is  established 
the  only  rational  treatment  consists  in  the  immediate  removal 
of  the  gestation-sac,  whether  it  has  ruptured  or  not. 

Abdondnal  section  is  the  most  satisfactory  method  of  operat- 
ing:, though  some  operators  prefer  th<;  vaginal  route,  The 
latter  method  has  many  disadvantages,  and  should  only  be 
n-orted  to  by  those  operators  having  sj)ecial  exj)erience  in 
()|H*rating  by  the  vaginal  route. 

As  it  is  a  matter  of  considerable  difficulty  in  many  cases  to 


208  PATHOLOGY  OF  PREGNANCY. 

control  the  licinorrliage  and  to  sej)arate  the  gestation-sac,  tho 
operation  of  dhdoniiiid/  .section  for  the  removal  of  an  ectopic 
gestation  should  not  he  undertaken  hy  an  unskilled  ojierator. 

The  technique  of  the  operation:  Tliough  the  o})eration  has 
fre(]uently  to  be  jx'rformed  in  an  emergency,  })lenty  of  lime 
shoidd  he  taken  to  secure  an  aseptic  condition  of  the  ahdoincii 
of  the  patient,  of  the  operator,  of  tlu;  assistants,  and  of  ihc 
instruments  and  dressings. 

The  oj)erator,  liaving  oi)ened  the  abdomen  by  a  medinn 
incision,  should  at  once  insert  his  hand  and  seize  the  afl'ectcil 
tube  at  its  uterine  end,  so  as  to  control  the  hemorrhage.  'Jlic 
broad  ligament  should  then  be  transfixed  by  a  pedicle-needle 
to  the  inner  side  of  the  roinid  ligament,  and  the  tube  ligatdl 
<ii  iiKi.s.se.  After  the  tid)e  and  ovarv  iiave  been  cut  awav,  t!ic 
abdominal  cavitv  shoidd  be  cleared  of  clots,  if  necessary  tlu.-h- 
ing  it  with  a  large  tjuantity  of  warm  sterile  water,  'riic 
incision  may  then  be  closed  without  the  insei'tion  of  a  drain- 
age-tube, unless  a  considerable  nund)er  of  adhesions  have  been 
encountered.  The  subse<]uent  treatment  is  the  same  as  for  :in 
uncomplicated  ovaviofomy. 

Wiien  the  hem  rrhage  has  been  very  considerable  a  (juaii- 
tity  of  sterile  sal'  solution  should  be  injected  under  encli 
breast,  during  the  (-,  ration,  by  an  assistant.  After  tlie  o])er- 
ation  it  is  advisable  in  all  cases  to  inject  at  least  a  quart  of 
the  same  solution  into  the  bowel,  by  means  of  a  long  rubber 
tube  and  gravity  syringe. 

In  advanced  ectopic  pregnancy  many  advise  that  interference 
be  delayed  until  just  short  of  term.  In  this  case  effort  shoiil.l 
be  made  to  enucleate    iiG  fo'tal  sac  whole. 

AVhen  this  is  found  to  be  im]K)ssible,  after  the  ftctus  li:i> 
been  removed  the  cori  should  be  cut  as  close  as  ])ossiblc  to 
the  jdacenta  and  the  e%es  of  the  sac  stitched  to  the  edge  o{' 
the  abdominal  wall,  and  the  sac  drained  by  packing  it  light Iv 
with  iodoform  gauze. 

The  after-treatment  in  such  cases  consists  in  daily  irrigatimi 
of  the  sac  with  antiseptic  solutions,  dusting  it  well  with  :tii 
antiseptic  powder,  and  introducing  fresh  packing. 

For  further  information  on  this  subject  reference  should  be 
Iiad  to  standard  gynaecological  Vvorks,  as  ectopic  gestation  has 


DIAGXOSIS  OF  OCCIPITOPOSTKIUOR   VASES.         209 

])  isst'd  from  tlie  domain  of  oh.sti'trics  to  that  of  gynax'ology, 
since  tlic  treatment  of  the  condition   is  pnrely  snrgical. 

PATHOLOGY  OF  LABOR. 

The  term  eutocia  is  api)lied  to  normal  hibor  which  termi- 
n  ites  easily  without  serious  damage  to  m-  ther  or  fetus  and 
AVitiiout  artificial  aid. 

Dystocia  is  the  term  aj)i)lied  to  abnormal  labor.  If  the 
al'iionuality  of  the  labor  <lepends  upon  some  form  of  fo-tal 
irit'iTidarity,  the  condition  is  termed  /"'fY^/  di/sfociti  ;  while  if  it 
h(  dependent  upon  some  abnormal  condition  in  the  mother  it 
i-  known  as  maternal  di/nfocia. 

fho  cause  of  the  dystocia  may  be  in  any  of  the  three  factors 
which  constitute  tlie  mechanical  problem  of  labor.  The  /Wy».s 
((!•  its  appendages  may  be  abnormal  in  si/e,  shape,  or  position  ; 
the  i.vix'Uim/  forces  may  be  insulHcient  or  excessive  ;  or  the 
resistance  offered  by  the  niaternal  panxaf/cs  may  be  too  great 
(IP  loo  little. 

When  called  upon  to  render  assistance  in  a  (;ase  of  dystocia 
the  |»hysician  should  first  ascertain  which  of  the  factors  is  at 
fault.  The  recognition  of  the  disturbing  cause  forms  the  basis 
of  rational  treatment. 

DYSTOCIA  DUE  TO  MALPOSITIONS  OF  THE  FlETUS, 

OCCI PITOPOSTERIOR   CASES. 

( )i'cii)itoposterior  positions  of  the  iiead  are  priniari/  or 
({f<liiir('(l. 

Primary,  if  the  head  enters  the  brim  of  the  pelvis  with  the 
occiput  })osterior. 

Acquired,  if  the  occiput  rotates  from  an  anterior  })osition  at 
the  i)eginning  of  labor  to  a  posterior  at  its  close ;  the  latter  is 
very  rare. 

Diagnosis  of  Occipitoposterior  Cases. 

Abdominal  examination:  The  back  of  the  fietus  m.;V  be 
felt  in  the  maternal  flank  ;  but  is  frequently  difti(rult  to  out- 
line. The  fetal  members  may  be  felt  over  the  whole  anterior 
[\<\)ir{  of  the  abdomen.     The   head  can  be  felt  at  the  pelvic 

1  l-Ob.-'t. 


210 


PATiroLoay  of  labor. 


brim,  wliile  the  unlcrior  slioiildt!!'  ran  easily  ho  distin^uislu  1 
at  a  point  al)()iit  midway  between  tlu;  middle  of  Pounan  > 
lij:CJHiient  and  the  iimhi liens.  The  f'cetal  heart-sonnds  mav  in- 
heard  in  the  Hank  at  abont  the  level  of  the  und)ilicns. 

Vaginal  examination :  If  the  eervix  '-•  dilated  sntlieieiitiv, 
the  saijittal  sntnre  may  be  felt  in  fhe  line  of  the  oblicjiic 
diameter  of  the  j)elvis,  while  the  })()sterior  fontr.nellc  is 
directed  toward  the  righi.  or  left  sacM'o-iliae  joint.  Labor  in 
oceipitoposterior  positions  is  generally  tedions  dne  to  the 
iri'egnlar  and  inetfe(^tiial  pains  which  eharacteri/e  the  fn>t 
stage  in  these  eas<'s,  and  also  Ix'cansc!  of  the  long  internal  idii- 
tion  which  mnst  take  place  before  the  oecipnt  is  direcinl 
under  the  pubic  arch. 

Mechanism  of  Occipitoposterior  Cases. 

In  normal  cases  the  mechanism  is  much  the  same  as  in 
anterioi'  positions  of  the  occiput.  Flexion  is  more  ditliciih 
on  account  of  the  maladaptation  of  the  head  to  the  ju-lvis  in 
these  posterior  ])ositions,  as  the  widest  ])art  of  the  head,  tlic 
biparietal,  is  in  relation  with  the  narrowest  part  of  the  inKt, 
the  diameter  between  the    iliopectineal  prominence  and  the 


Fig.  67. 


Fig.  68. 


Riglit  nrcipitopnstorior  position  of 
licnd.  'I'lie  arrow  sliows  tho  <lirt'('tion  of 
till'  loTiK  internal  rotation  made  by  tlio 
oecipnt  in  delivery.    (Jowett.) 


Left  oeripitopostcrior  position  of  lu'inl. 
Tlie  arrow  siiows  the  direction  of  tlie  Ioiil' 
internal  rotation  made  by  the  occiput  in 
delivery.    (Jewett.) 


promontory.  When  flexion  is  complete  and  the  head  ^V'- 
scends  to  the  pelvic  floor,  internal  rotation  is  {)rolonged  <iii 
account  of  the  great  distance  the  occiput  must  traverse  to 
come  under  the  pubes ;  hence  there  is  greater  pain,  and  the 
labor  is  prolonged  (Figs.  67  and  68). 


MI'JCIIAMSM   OF  OC('iriT()I'()STi:Rl(fIt   CASKS.       211 

Abnormal  Mechanism. 

( 1 )  Extended  position  of  head:  'IMu'  (lisproportion  lK't\v»Tn 
tilt'  (K'(Uj)ital  ('11(1  of  tlio  head  and  that  jxd'tioii  of  the  hrim  in 
relation  to  it  already  rel'erred  to,  may  result  in  interference 
wiili  flexion  to  sneh  aji  extent  that  the  head  may  enter  the 
j)(  Ivis  in  an  extended  position,  as  in  hrow  or  I'aee  presenta- 
tions. 

('2)  Face  to  pubes :  When  the  hea<l  enters  tlie  pelvis  imper- 
fcctlv  flexed  the  sinciput  may  reach  the  jielvic  floor  first,  and 
is  then   directed  toward   the  pubic   arch,    while  the  occii)iit 

Fio.  69. 


Fiiiilty  mechanism  in  a  ripht  ()coii)it<)post(_'ri()r  cnse.    The  occiinit  is  shown  rotatiiiy 

to  the  baelc.    (After  Schuttze.) 

rotates   into   tlie    hollow    of   the    sacrum.     This    mechanism 
results  in  delivery  "  face  to  pubes." 

In  such  ])ersistent    oecipitoposterior   cases    tlie    head  con- 
tinues to  descend  until   the  glabella  (the  root  of  the  nose) 


L 


212 


PATHOLOGY  OF  LABOR. 


pivots  imdor  tlu;  j)ul)es,  whon  Hcxioii  takes  pla'^o  to  ]>erniit  ic 
(v-capo  of  tli<'  <»('(  ipiit  over  tlu-  p<'riiu'iim.  Wlicn  the  occipn  i^ 
(l(;livt'i*c'(l  tlw  li('a<l  cxtcmls  uii«l  tlic  tiicc-  escapes  iVoni  uikI'T  ;  ic 
j>ul)es(Fi<^.  ()!)).  Sj)ontanoous(leliverv  in  a  t'ae(.'  to  pulx's  ea>'  i> 
only  a('(;om|>lislu'(l  witli  ditlieiilty,  ami  re(jiiires  stronjr  paii*, 
lax  maternal  [)arts,  jiiid  lu  t  too  large  a  head.  After  the  hi  ih 
of  the  head  the  nieehaiiism  is  the  same  as  in  other  eases. 

(o)  In  other  cases  the  head  may  enter  the  pelvis  po.  1\ 
l]exe<l,  d(!seend  nntil  it  reaches  the  pelvic  Hoor,  and  tli  iv 
remain  fixed  with  its  foiif/  (lidiiictcr  (().  F.)  fnin.sirr.Hc  in  'h, 
jK'/i'ic  ('(trifi/,  generally  at  the  level  of  the  i.schial  spine,. 
between  which  it  l)e<'omes  imj)acted. 

Moulding  of  head  in  face  to  pubes  cases:  The  occipito- 
mental and  occij>itolVontal  diameters  of  the  f<etal  head  .iic 
shortened  and  the  sul)0(('i[)itol)regmatic  lengthened,  a-  a 
result  of  the  head  pivoting  at  the  glahella  (Fig.  70). 


Fig.  70. 


Management  of  Labor  in  Occipitoposterior  Cases. 

Prophylaxis:  vVttention  ha<  been  drawn  to  the  desirahilitv 
of  making  an  abdominal  examination  to  determine  the  pn>i- 

tion  of  the  fcetns  some  time  bcturc 
the  expected  onset  of  labor.  If  at 
this  examination  the  fa'tns  be  Inmid 
to  occupy  a  posterior  position,  it  i- 
possible  to  rectify  it  by  })ostural  treat- 
ment in  many  cases.  The  woman 
should  be  instructed  to  assume  the 
knee-chest  ])osition  as  frequentiv  a- 
possible,  and  to  remain  in  this  jwsitidii 
for  some  time  before  turning  iiimhi 
the  side  to  which  it  is  desired  [>> 
direct  the  occiput.  In  this  po>tiirc 
the  tendency  is  for  the  child  to  siii 
away  from  the  brim  under  the  iiitlii- 
ence  of  gravity,  as  the  fundus  and 
anterior  uterine  wall  become  the 
lowest  ]iortions  of  the  uterus.  Tlif 
child  thus  becomes  free  to  rotate  upon  its  own  axis,  aii<l  :i« 
its  dorsum  is  heavier  from  the  presence  of  the  spinal  column 


Dinjiram  showiiiK  lioad  iiii- 
iiioulilfd  1111(1  iiii)iil(k'(l  ill  11  per- 
sistent (ieeii)ito|i()steri()r  ciise. 

151ael<,  umiiouldofl. 
Rod,  inouldeil. 


LMi  >  i   IN  Oi'ClJ'ITorOSTEJtKJii   (Vl^AX  213 

ii  is  hroiiulit  into  apjio-^itloii  with  the  anterior  wall  of  tiic 
iiurtis.  IIciico  as  tiio  woman  assumes  the  erect  posititm 
the  child's  head  tends  to  settle  tlown  a<^ainst  the  brim  in 
iui  anterior  j)osifion. 

At  the  Peldc  Inlet. 

Fre((nent  examinations  should  be  n)ade  to  ascertain  wliether 
ll  \i(>n  is  heino'  maintained  as  the  head  descciid>  into  the  brim. 
Sliould  extension  of  the  he;'.«l  take  jdace  without  descent, 
iiiterl'erenee  is  demanded,  as  tliere  is  l)ut  little  likelihood  that 
the  head  will  pass  the  brim  by  natural  etlbrts. 

Tlircc  iiHthods  of  dc/lrcri/  are  possible  : 

1st.  Version  :  Tiiis  is  probably  the  most  popular  as  well  as 
the  easi(,st  method  of  dealing  with  these  cases,  because,  as  a 
rule,  the  general  practitioner  can  perform  thi>  operation  with 
LTcater  ease  to  himself  and  less  danger  to  the  |)atient  than 
citiier  of  the  other  methods. 

2d.  Normal  restoration  of  flexion  and  rotation  of  the  foetal 
head  and  body  to  an  anterior  position,  with  the  subsequent  ap- 
plication of  the  forceps  :  This  is  a  rather  ditlicult  oj)eration,  and 
>hould  only  be  undertaken  by  tiiose  who  are  thoroughly 
skilful  in  the  use  of  force])s.  To  perform  this  operation 
|)i(i|)erly  the  patient  should  be  placed  under  the  influence  of 
cliioroform,  so  as  to  relax  thoroughly  tlie  uterus.  '^Phe  opera- 
iov,  after  the  usual  anti;n'j)tic  ])rccautions  have  been  observed, 
sliDuld  then  ])ass  his  whole  hand  into  the  uterus  so  as  tirmly  to 
giasp  the  brow  and  face  of  the  child.  The  head  having  been 
raised  slightly,  so  as  to  free  it  from  the  brim,  is  then  gently 
rotated  to  an  anterior  position.  The  external  hand  of  the 
opci'ator  should  be  used  to  ])romote  rotation  of  the  trunk, 
which  should  accompany  rotation  of  the  head.  The  rotation 
should  be  carried  out  slowlv  and  with  the  utmost  i»;entleness. 
After  this  lias  been  accomj)lished  the  head  should  be  urged 
into  the  brim  by  external  pressure,  and  shoulil  be  maintaine<l 
ill  j)osition  by  an  assistant  while  forceps  aj)plication  is  made. 
As  in  all  high  operations,  only  the  axis-traction  forceps  sliould 
he  used. 

3d.  Application  of  the  forceps  without  alteration  of  position  : 
This  operation  should  only  be  undertaken  as  a  last  resort,  as 


214  I'ATUOLOGY  OF  LAIiOR, 

it  is  vorv  dangerous  both  to  iiiotluir  and  cliild.     As  ii  pic- 
lituinary  to  this  operation  tlic  lioad  should  be  flexed. 


In  the  Pelvic  Cavity. 

As  in  all  posterior  j)()sitions  the  iiead  tends  to  pass  the  brim 
in  a  soniewiiat  extended  position,  it  is  iin[»ortant  to  seeiiii  ;i 
speedy  restoration  of  flexion,  in  order  that  the  labor  niav  1m 
aeeoinplished  as  easily  and  rapidly  as  possible,  and  to  sj);ir(' 
the  j)atient  unnecessary  sullering. 

Flexion  may  l)e  restored  by  pressure  upward  upon  tlic 
sinciput  with  two  tin^a-rs  during  the  intervals  between  the 
])ains.  J)uring  the  ])ains  the  descent  of  the  sinciput  may  he 
retarded  by  niaintaininjr  this  pressure  from  below.  Oceasinn- 
ally  it  is  possible  to  hook  the  finger  of  the  other  hand  om  r 
the  occiput  and  draw  it  down,  while  at  the  same  time  the 
sinciput  is  being  pressed  up;  but  to  do  this  the  head  must  lie 
very  low  and  the  j)arts  lax. 

When  rotation  fails  and  signs  of  exhaustion  occur,  then  tlic 
forceps  must  be  applied.  During  this  operation  care  sluniM 
be  taken  to  prevent  the  blades  slipping,  as  this  accident  is  very 
liable  to  occur.  Between  the  tractions  the  blades  should  he 
separated,  because  sometimes  the  occijuit  tends  t(>  rotate  spon- 
taneously. As  the  head  emerges  it  should  flex  and  the  root  oi' 
the  nose  ])ivot  under  the  pelvic  arch.  It  should  be  delivciid 
slowly  and  with  extreme  caution,  so  as  to  favor  moulding  ;iii<l 
to  control  the  extent  of  perineal  laceration.  In  many  cas"s 
it  is  necessary  to  perform  e])isiotomy,  in  order  to  ])revent  the 
laceration  of  the  perineum  extending  into  the  rectum. 


Prognosis. 

The  prognosis  for  both  mother  and  child  is  not  so  favorable 
as  in  anterior  positions.  Backward  rotati(tn  of  the  occi|»iit 
takes  place  in  about  1|  per  cent,  of  all  cases  of  labor. 

Laceration  of  the  maternal  soft  parts  is  frequent  and  oltcn 
extensive.  The  mortality  of  the  fietus  is  somewhat  over 
9  per  cent.,  as  compared  with  5  per  cent,  in  anterior  jxtsi- 
tions. 


DIAGNOSIS  OF  FACE  VltESESTATlOSS.  215 

FACE   I'KKSKNTATIONS. 

Occurrence  :  Fuco  prosoiitations  rarely  exist  prior  to  the 
onset  of  labor;  tliey  may  l)e  considered  as  altered  vertex  pres- 
(  Illations.  I'i'esentation  ol'tlu;  I'aee  cannot  be  said  to  l)o  (!oni- 
iiion,  for  it  o(!('nrs  once  in  abont  everv  'JoO  cases  of  labor. 

Positions:  Tlie  chin  is  the  denominator,  as  it  replaces  the 
(tccipnt  in  the  m(!chanism  when  I'ompai'ed  to  vertex  picsenta- 
tions,  for  the  head  is  extended  instead  of  Ix-inji;  Hexed. 

Th(;  lon<^  diametcir  of  the  face,  the  frontomental,  nsnally 
occnpies  the  ri>j;ht  obli«pie  diameter  of  tin-  jx'lvic  brim  ;  hence 
tiic  most  common  positions  are  :  Iv.  JNI.  1*.  and  L.  M.  A.; 
rarely,  R.  M.  .V.  and  L.  M.  I*,  jxtsitions  may  be  met  with. 

Causes  :  Any  condition  which  tends  to  interfere  with  proper 
th.'xion  of  the  head  may  be  set  down  as  a  cause  of  face  pnis- 
ontation.     The  most  common  causes  are  : 

1.  Oblicpiity  of  the  uterus,  which  acts  by  altering  tiie  line 
of  fetal-axis  j)ressure. 

2.  Tumors  of  the  fetal  neck,  thyroid,  or  thymus. 
.'».  Coils  of  thick  e«)rd  around  the  neck. 

4.  Dead  fetus, 

5.  Kxeessive  li((Uor  anmii. 

6.  Small  size  of  fetus. 

7.  Deformcid  pcilvis. 

8.  Tumors  of  uterus  or  nei<^liborin<»;  structures. 

9.  Tumors  upon  the  ba(!k,  as  meningocele. 

10.  Dolichocephalic  head. 

11.  Occipitoposterior  positions,  in  which  there  is  a  tight  fit 
at  the  brim. 

Diagnosis  of  Face  Presentations. 

Abdominal  examination:  It  is  sometimes  a  matter  of  difh- 
culty  to  make  a  diagnosis  of  face  presentation  when  the 
abdominal  wall  is  thick  or  tense.  Usually  the  bulivy  cranial 
vault  can  be  felt  in  one  hypogastric  I'cgion,  and  a  deep  groove 
may  be  made  out  between  it  and  the  fietal  back.  On  the 
opposite  side  of  the  abdomen  the  fetal  members  may  be  dis- 
tinguished (Fig.  71).  As  the  fcetal  back  is  displaced  from 
the  uterine  wall  by  the  extended  head,  the  hi'drt-Hounih  are  to 


21<i 


PATllOLOdY  OF  LA  noli. 


ho  heard    most  distinct ly  on  tlu;  same  side  of  the  alxloiiui 
upon  which  t..«»  fci'tal  cxtreniitics  are  ..It. 

Vaginal   examination:     Karly  in    lahor  hcforo   niptnro  ni 
the  nioinhranes,  tiie   rounded   head   to  be  felt   in  tiie  vertc:. 


Fia.  71. 


Transverse  pos'Hon  of  face  at  superior  strait. 

cases  is  wanting,  and  usually  nothing  can  be  readied  but  tlic 
b  dky  bag  of  waters,  as  tiie  face  is  arrested  high  up  Caiv 
lould  be  taken  not  to  rupture  the  membranes  in  attcm])tini: 
to  reach  the  presenting  jiart  of  the  fcctus.  Should  the  bag  of 
waters  be  ruptured,  then  it  may  be  possible  to  distinguish  the 


Mi:('ll.l\fSM  OF  l'\\('I<:  rHESESTATIoSS.  217 

i!|)('n'iliary  rifle's,  the  eves,  tlic  iiosi',  niid  especially  the  moiitii. 

i  lie  latter  is  distin^iiislied  hy  I'eeliiin;  the  tongue  and  the 
;ilve<>lar  marjjiiis.  It'tlu!  caput  siu'cedancjim  has  loniied  ovei" 
liie  (ace,  it  may  he  mistaken  ior  a  hreech,  unless  can-  he  taken 
|.i  distini^niish  clearly  the  relationship  of  the  parts  within 
nach  «»1"  the  linger. 

Mechanism  of  Face  Presentations. 

The  first  stage  of  labor  is  delayed  hecanse  the  head  does 
iiiit  lit  the  lower  nterine  segment  so  well  as  in  vertex  presen- 
taiions. 

The  mechanism  of  face  cases  differs  fr(»m  that  of  the 
V(  rtex   in   that  : 

1.  The  chin  takes  the  j)lace  of  the  oc''ij)nt  in  heing  the 
l(;i(liiig  ))art  of  the  head  in  descent.  It  <loes  not  come  down 
so  far  in  advance  of  the  rest  of  the  head  as  the  occi|)nt  in 
V(  rtex  cases,  so  that  internal  rotation  of  the  chin  forward  to 
the  pnl)ic  arch  occurs  rather  lat(!  and  is  slow. 

2.  Monlding  takes  place  with  more  dillicnlty  than  in  vertex 
cases. 

.').  The  head  is  (lelayed  longer  at  the  brim,  as  extension 
lias  to  he  very  marked  hefore  de-cent  can  begin;  hence,  as  a 
rule,  labor  is  delayed. 

\i.  M.  P.  :  As  this  is  probably  the  commonest  position,  its 
mechanism  will  be  described  in  detail. 

The  long  diameter  of  the  face,  the  frontomental,  descends 
tiirongh  the  inlet  in  the  right  oblicpie  diameter  of  the  ])elvi(^ 
luirn.  The  chin  descends  along  the  j)osterior  pelvic  groove 
(111  the  right  side  till  it  strikes  the  j)elvic  Hoor,  then  it  rotates 
fnrward  through  three-eighths  of  a  circle  on  the  right  side  of 
tlic  pelvis  till  it  comes  under  the  ])nbic  arch.  The  brow 
rotates  into  the  hollow  of  the  sacrum,  and  the  frontomental 
diameter  thus  corresponds  to  the  anteroj)osterior  diameter  of 
llic  outlet.  The  chin  then  a|)pears  at  the  vulva  and  escajH's 
heiieath  the  pubic  arch.  The  movement  of  flexion  then  be- 
j.'^'ns,  the  chin  ])ivoting  under  the  pubic  arch,  and  the  face, 
torohead,  vertex,  and  occiput  suc(essively  clear  the  j)erineum 
(Fig.  72).  The  head  now  being  free  assumes  its  relationship 
t(»  the  shoulders,  which  occupy  the  right  oblique  diameter  of 


218 


PATHOLOGY  OF  LABOR. 


tli(!  pelvis  ;  the  rest  of  tlie  meclianisni  is  the  same  as  in  a  ca^r 
ofL.  ().  A. 

L.  M.  A. :  Tiie  niechaiiisin  is  tiie  same  as  in  a  vertex  ease, 
except  tliat  the  occiput  is  replaced  by  the  chin,  which  pivot-; 

Fig.  72. 


Diagrammatic  view  of  moclinnism  in  n  riglit  montopnstcrior  pos('io?i  of  a  face 
ptmcntntiDH,  chin  rotatinf^  to  jmlics. 

•.indor  the  puhes ;  then  the  head  is  delivered  by  flexion. 
Sometimes  in  a  larire  pelvis  the  head  may  be  pushed  throuoli 
in  extension  without  any  special  mechanism. 

In  mentoposterior  positions  the  head  may  descend  into  the 


MAXAaEMENT  OF  FACE  PliESEyTATIOXS. 


219 


itclvis  sunicMcntly  far  to  prevent  completely  the  anterior  rota- 
tion of  the  eliin,  whieh  is  then  forced  into  the  hollow  of  the 
-Mcrnni.  This  c(  idition  is  practically  fatal  to  the  child,  for 
the  author  has  been  able  to  Hnd  hut  one  case  recorded  in  which 
a  living  child  was  horn  after  this  accident  had  occurri'd. 

Head-moulding:  Tiie  vault  of  the  head  heconies  flattened 
and  ])ushed  backward ;  the  diameters  lengthened  are  the 
(iccipitofntntal  and  the  occipitomental  ;  the  diameiers  short- 
(■ii('(l  are  the  snboccipitobregmatic  and  tlie  cervicobregmatic. 

The  caput  succedaneum  is  found  on  the  face,  (;hieHy  around 
the  eye  which  lies  anterior  wiien  the  face  is  at  the  brim  ; 
(»\\ing  to  the  laxity  of  the  tissues  of  the  face  the  swelling  is 
(iften  very  great  and  the  discoloration  considerable.  The 
eve  may  be  closed  for  days,  and  the  child  may  be  unabU;  to 
suckle  from  the  swelling  of  the  li})s. 

Prognosis. 

The  fd'tal  mortality  in  face  oases  is  about  15  per  cent.; 
the  maternal  mortality  is  given  as  being  over  6  per  cent., 
for  these  cases  are  fre(piently  mismanaged.  The  labor  is 
tedious,  as  a  rule.  Anterior  positions  of  the  chin  are  better 
than  posterior,  as  the  labor  is  quicker.  There  is  usually 
more  or  less  serious  laceration  of  the  perineum. 


Management  of  Face  Presentations. 

The  important  point  in  the  first  stage  is  to  preserve  the  bag 
of  waters  intact  ih  long  as  [)ossible,  because  the  face  is  a  ])oor 
dilator  of  the  cervix.  The  patient  should  therefore  be  kept 
ill  bed  all  through  this  stage. 

Flexion  by  Sch'  3's  method:  If  the  chin  is  posterior  an 
attempt  should  be  made  to  restore^  flexion  and  thus  convert 
the  position  into  a  vertex  anterior.  This  may  be  accomplished 
l)y  gentle  external  mani|)ulations  according  to  the  method 
recommended  by  Scliatz  (Fig.  7-\).  The  woman  is  ])laced  in 
the  Trendelenburg  ]>osition,  which  may  be  accomjdished  by 
arranging  an  ordinary  wooden  chair  (first  sawing  off  the  legs 
close  to  the  wooden  seat)  on  the  bed  so  that  its  back  forms 
an    inclined    plane,  covering   il   with  a  folded    blanket   and 


220 


PATHOLOGY  OF  LABOR. 


dravving  tho  patient  up  over  it  so  that  iier  huttoeks  rest  on 
tlie  back  edge  of  tlie  seat.     Tlie  operator  tlien  presses  on  tli 
oceiput  of  the  eliihl  \vith  one  hand,  so  as  to  force  it  into  tli 
pelvis,  while  he  presses  the  other  against  the  child's  neck  o  ■ 
the  opposite  side,  thus  Hexing  tlie  head  and  straiglitening  tli  • 
vertebral  .'olunin  of  t'  ^  fcetus.      When  flexion  has  thus  been 
accomplished,  ])ressure  is  then  maintained  upon  the  fundus,  >n 
as  to  for(!e  the  head  into  the  })elvic  brim  in  the  flexed  ])ositi()ii. 
If  this  !)e  found  impossible,  the  case  may  be  left  until  tin 
OS  has  dilated,  when,  after  ruj)turing  the  membranes,  an  etlort 

Fig.  73. 


<-«« 


Schatz's  meUiod  of  rectification  by  external  nianiinilatiun. 

may  be  made  to  restore  flexion  by  introducing  the  hand  into 
the  uterus. 

If  it  be  found  im])ossible  to  maintain  the  head  in  the 
flexed  position  after  this  manauivre,  the  forceps  should  be  ap- 
plied and  the  head  drawn  down  into  the  cavity  in  a  flexed 
j)osition,  when  the  bla<les  may  be  withdrawn  and  the  deliverv 
left  to  nature. 

If  the  ])atient  is  a  multipara  with  lax  ])arts  and  the  uterine 
contractions  are  powerful,  the  case  may  be  left  to  nature  ;  but 
care  should  be  exercised  to  secuie  good  extension  as  the  head 
descends,  in  order  that  the  chin  may  reach  the  pelvic  floor  in 
advance  of  the  I'cst  of  the  head. 

In  a  primipara  in  whom  the  presentation  is  posterior  and  it 


liREECII  rEESENTATIONS.  221 

IS  found  impossible  to  restore  flexion,  intcnial  vcrmm  may 
lie  cinployetl. 

Forceps:  If  version  be  impossible!  in  anterior  positions 
A  here  delay  ocenrs  at  tlu;  l)rim,  then  forceps  may  l)e  apj)lied  ; 
i)ut  the  operation  is  difficult  nnd  danu:<'rous,  as  the  blades 
lend  to  slip  off  the  head  when   traetion   is  made. 

If  all  these  efforts  fail  and  the  child  has  perished,  then 
craniotomy  must  be  performed   to   secure  delivery 

When  the  head  has  })assed  the  brim  and  fails  to  advance  fur- 
ther, there  is  (lanji;er  to  the  child  from  tension  on  the  vessels  of 
ilie  neck  causing en<:;orjrement  of  the  cerebral  circulation.  In 
-iich  cases  the  forceps  should  be  eniployed  to  hasten  delivery. 

Symphysiotomy  has  been  recommended  in  cases  of  persistent 
inentoj)osterior  positions  if  the  child  is  living. 

Brow  Presentations. 

Many  authc  'ities  describe  a  half-way  stage  in  the  develop- 
iDcnt  of  face  presentations.  It  can  scarcely  be  classified  as  a 
special  presentation,  but  i^hould  be  considered  as  sim})ly  a  dis- 
placement of  the  vertex. 

Sliould  such  a  presentation  be  met  with,  it  can  oidy  be  diag- 
nosed by  vi'ginal  examination.  The  extension  of  the  head  is 
recogniz'jd  by  the  flu^t  that,  instead  of  the  vertex,  the  finger 
comes  in  contact  witli  the  brow;  possibly  the  anterior  fonta- 
iielle  may  be  distinguished,  as  well  as  the  su|)ra-orbital  ridges. 

Treatment  consists  in  the  manual  restoration  of  flexion  ; 
and  if  this  be  impossible,  version  must  be  resorted  to  in  order 
to  effect  delivery  with  a  minimum  of  risk  to  the  mother  and 
child.  In  rare  instances  in  which  the  brow  is  directed  ante- 
riorly the  head  may  descend  to  the  pelvic  floor  in  this  ptirtially 
extended  condition;  in  such  cases  the  sinciput,  being  in 
advance  of  the  rest  of  the  head,  is  directed  to  the  pubes, 
the  root  of  the  nose  pivots  under  the  pubic  arch,  and  the  head 
is  delivered  in  flexion,  ])recisely  the  same  as  has  been  de- 
scribed in  speaking  of  "  face  to  pubes "  cases. 

imEECII  PRESENTATIONS. 

Definition:  The  presentation  of  any  part  of  the  pelvic  pole 
of  the  feetal  ovoid  at  the  inlet   is  termed  a  breech  presenta- 


222 


PArilOLOGY  OF  LAROR. 


tion.  The  term,  therefore,  inehides  a  presentation  ot'tlie  Imi 
toch,  /cncrti,  or  feet.  Tlie  denomination  is  taken  from  tlii 
position  of  tlie  sacrum. 

Frequency  :  Jireecli  presentations  occur  in  the  proportion  ol 
1  in  30  labors;    if  premature  births  be  excluded,  then  tli. 


Fi(!.  74. 


Breech  presentation.    Right  sacroposterior.    Feet  and  cord  in  relation  to  os  inter 

num.    (After  A.  li.  Simpson.) 


proportion  is  about  1  in  60.  The  positions  in  order  of  fre- 
quency are  :  L.  S.  A. ;  R.  S.  P. ;  R.  S.  A. ;  L.  S.  P.  (Fiys. 
74  and  75). 

Causes:  Certain  conditions  favor  presentation  of  thebrcocli. 
These  are  :  lax  uterine  or  abdominal  walls,  excessive  licpior 
amnii,  uterine  obliquity,  multiple  pregnancy,  death  or  pi-eni:i- 


DIAGNOSIS  OF  BRKKCII  PKESEyTATIOyS. 


2ti;5 


tiiritv  of  tlio  fd'tiis,  placonta  pnevlii,  contractcHl  pelvis,  tumors 

ot    tlio    uterus    or   neigliboring  structures,    monstrosity,  and 

Intlroeephalus. 

rui.   to. 


Brocch  presentation.    Left  sacro-anterior  position.    (After  A.  H.  Simpson.) 

Diagnosis  of  Breech  Presentations. 

Abdominal  examination  :  On  exploring  the  e.xeavation  of  the 
|>('l\  is  it  will  be  found  empty,  while  at  the  brim  a  large,  bulky, 
incouliir,  movable  mass  may  be  distinguishe<l,  whieh  is  not 
('iiii;:ige<l  unless  labor  has  well  advanced.  At  the  fundus  the 
hard,  well-defined  contour  of  the  head  will  be  easily  reeog- 
ni/ed.  The  festal  heart-sounds  will  be  heard  on  the  side  to 
wiiich  the  back  is  directed,  at  or  above  the  level  of  the  um- 
bilicus. 


224  PATII0L0(}Y  OF  LABOR. 

Vaginal  eximination :  Care  must  l)o  taken  not  to  riiptii  > 
the  UKMiibi'anes  if  they  I)e  found  intact,  in  niaiving  tlie  vagiir  1 
examination.  Generally  the  hreeeh  is  situated  so  higli  i  :i 
that  it  cannot  be  reaehed  without  risk  of  ru})turinjr  the  h;  .r 
of  waters  if  the  examination  is  made  early  in  labor.  Aft  v 
labor  has  advanced  and  the  membranes  have  ru[)tured  tl  ■ 
breecli  may  be  recognized  by  feeling  the  sa(;rnm,  coccyx,  a.  I 
ischial  tuberositi(!s  of  the  fetus.  The  anus  mav  be  rec(»<;n!/  I 
1)V  the  grasj)  of  the  sphincter  ani,  and  '  y  the  presence  of  in  - 
eonium  on  \\u\  examining  finger.  If  the  child  is  a  male,  tlic 
scrotum  and  penis  may  be  felt.  Occasionally  the  former  iii.iv 
be  fedematoiis  and  may  then  be  mistaken  for  the  bag  of  w ati  r-. 
One  or  both  feet  may  be  felt;  the  foot  may  be  distinguished 
from  the  hand  by  the  projections  of  the  heel  and  the  malleoli. 
The  knee  may  be  distinguished  from  the  elbow  by  the  pn  >- 
ence  of  the  ])atella  and  by  the  larger  size.  Care  must  In- 
taken  to  distinguish  the  breech  from  the  face,  for  which  it  is 
often  niistidicn. 

Mechanism  of  Breech  Presentations. 

The  first  stage  of  labor  is  very  prolonged,  for  the  brc"  rh 
forms  a  poor  dilator  of  the  cervix,  and  <m  account  of  its  soft- 
ness acts  imperfectly  as  an  irritator  of  reflex  uterine  contrac- 
tions. 

The  breech  descends  generally  with  the  anterior  hip  slight Iv 
in  advance  of  the  other.  The  anterior  hij)  in  striking  the 
pelvic  floor  is  rotated  forward  to  the  pubic  arch,  where  it  be- 
comes fixed,  while  the  trimk  is  driven  down  and  the  ])()sterinr 
hip  moves  forward  over  the  perineum  (Fig.  70).  Generally 
both  hij)s  emerge  through  the  vidva  at  the  same  time,  then 
follow  the  thighs  and  trunk.  If  the  legs  are  flexed  properly, 
they  generally  escape  with  the  thighs  and  breech. 

The  shoulders  pass  the  brim  with  their  long  diameter  trans- 
verse ;  they  then  turn  into  the  oblicpie,  and  finally,  at  the  out- 
let, into  the  antero])()sterior  diameter.  The  anterior  shoiiMer 
is  generally  delivered  first,  followe<l  by  the  posterior. 

The  head  by  this  time,  if  flexion  has  been  maintained  I)y 
active  external  contractions,  has  entered  the  brim  with  its 
long  diameter  in  the  opposite  oblique  diameter  of  the  pelvis 


MECnAMS}f  OF  miEECII  PIIKSESTATIONS. 


22.-) 


(m  tluit  ill  wliicli  tlie  sIm)ii1<1(M's  engaged.  TIic  occiput  usually 
sii'lkcs  the  pelvic  floor  first  and  rotates  to  the  front,  while  the 
t'M't'  is  directed  to  the  hollow  of  the  sacrum.  riie  face  and 
t'lrehead  are  then  horn,  followed  by  the  rest  of  the  head. 

Abnormalities  in  the  mechanism  :  1 .  The  hrccch  may  he  ar- 
rested at  the  brim  or  niav  not  en":a«»e.  This  mav  he  due 
cither  to  pelvic  contraction  or  to  excessive  si/e  of  tlu?  fu'tus. 

"2.  The  hrcccli.  may  descend  into  the  cavity  of  the  pelvis 
and  there  be  arrested.  This  may  be  due  to  excessive  size  of 
tlic  tu'tus,  to  imperfect  dilatation  of  the  external  os,  to  pelvic; 
(1(  f'ormity,  or  to  the  extended  j)ositi()n  of  the  lind>s  along  the 
i)<)dy  of  the  child  preventing  its  lateral  flexion. 

lM(i.   7C). 


Passage  of  buttocks  over  perineum  iu  ii  breech  case.   (After  Barnes.) 

.').  The  (ii'inx  may  become  extended  and  cause  arrest  of  the 
luad  at  the  pelvic  brim.  This  accident  may  be  due  to  an 
iiiiixrfectly  dilated  os  or  to  pelvic  contraction.  It  is  very  apt 
t(i  occur  if  traction  is  made  upon  the  body  of  the  fretus  to 
accelerate  delivery. 

I.  The  hf(uf  may  become  arrested  at  the  brim  or  in  the 
pelvic  cavity,  as  a  result  of  extension  or  from  ])elvic  deformity. 
Occasionally  when  the  ftice  is  directed  anteriorly  the  chin  may 
catcji  on  the  upper  border  of  the  pubes  and  cause  delay. 

Moulding  of  the  foetus  :  The  breech  is  generally  swollen  and 
ot'toii  discolored  from  eechymoses ;  the  discoloration  is  generally 

15— Obst. 


226  PATJiOlJjaY  OF  LABOR, 

more  nuirkccl  over  tlio  anterior  liip.    If  the  child  is  a  male,  tin.' 
scrotum  is  jreiierally  (edematous. 

Prognosis  of  Breech  Presentations. 

The  foetal  mortality  varies  from  10  to  .'50  j)er  cent.,  depeml- 
iu<;  upon  the  skill  of  tlu;  physician.  The  risks  to  the  eliil  I 
are  orcat,  due  to  the  prolapse  of  the  cord  and  the  j)ressure  df 
the  aiter-cominjij  head  uj)on  it.  Fractures  and  dislocations 
may  he  caused  by  etforts  at  rapid  delivery. 

The  risks  to  the  mother  are  increased  only  hy  tiie  tenden.  v 
to  laceration  and  to  bruising  of  the  soft  parts  on  account  dl' 
the  necessity  for  rapid  and  sometimes  violent  extraction  of 
the  after-coming  head. 

Management  of  Labor  in  Breech  Presentations. 

General:  Very  earlv  in  lahor,  before  the  membranes  have 
ruptured  or  the  breech  has  bet;ome  engaged  in  the  brim,  it 
may  be  j)ossible  to  perform  an  external  version.  The  o|)cra- 
tion  is  not  always  practicable,  and  therefore  shoidd  not  he 
attempted  unless  there  is  certainty  that  it  can  be  successfully 
accomplished. 

The  position  (►f  the  ])hysician  in  charge  of  a  breech  case 
should  be  one  of  armed  ex})ectancy.  As  long  as  th(,>  natinal 
processes  are  progressing  satisfactorily  lie  should  be  watclit'iil 
but  inactive,  and  should  be  prepared  to  interfe^  '  promj)tly  (ui 
the  appearance  of  danger  to  the  child. 

Wlien  ]K)ssible  a  skilled  assistant  should  be  obtained,  whnsc 
duty  it  is  to  give  the  an.'esthetic  and  attend  to  the  maintenance 
of  pressure  upon  the  finidus,  so  as  to  prevent  extension  of  tlic 
head  during  the  delivery. 

Preparations  should  be  made  for  treating  asphyxia  of  tli( 
newborn  infant.  At  hand  should  be  placed,  sterilized  and 
ready  for  use,  the  ligatures  for  the  co»'d,  scissors,  two  pairs  of 
artery-forceps  (to  be  used  instead  of  ligatures  in  cases  in  wliidi 
speed  is  demanded),  a  basin  containing  warm  sterile  water  in 
which  are  a  couple  of  sterile  towels  for  wrapping  ar<tnn<l 
the  child's  body  during  delivery,  and  the  ordinary  obstetric 
forceps. 


M  ly.KiKMl'JNTOF  LAJiOU  L\  lilih'h'CIl  rJih\Si:.\TATl()ys.  227 


Throughout  labor  tlio  pationt  sliouM  l>r  kept  in  Ix'd,  and 
>li(»iil(l  1)(!  caiitioiicd  aijainst  strainiiiii- diiriiiLr  tlic  lir<t  stai^c,  as 
it  is  desirahle  to  retain  tiic  iiu'iiihrancs  witiiotit  rupture  as  loiin; 
ii-i  p()ssil)ie,  to  favor  eoini)let"  dilatation  of  the  os  nteri.  I'lie 
t'd'tal  lionrt-sonnds  should  bo  freciucntiy  auseuhated  (hiring;  tiic 
H'cond  staj^e  of  hihor,  since  there  is  always  dan«:;er  of  com- 
pres>;ion  of  the  cord.  IiTej^ularity  of  the  heart-heats  is  suf- 
liiicnt  cause  for  interference. 

When  delivery  is  imminent  the  j)atient  should  lie  in  the 
il.irsal  j)osition,  with  the  thit^hs  flexed.  In  cases  in  which  it  is 
iit'ccssary  to  etVcHit  a  speedy  delivery  the  paticiit  shoidd  he 
placed  across  the  bed  in  the  lithotomy  position.  As  soon  as 
the  buttocks  enieru;e  they  should  be  wrapped  inajvui'ni  ;?t<'rile 
'I.  to  prevent    the    child    inakinir  eiu)rts   at    rcsi)ii-ation. 


pro 


'V 


lowe  ,  .__»_———_ t        . ..._ 

Kroin  the  moment  the  buttcx'ks  appeaFat  tlie  viTIva  till  the 
placenta  is  delivered  the  fundus  uteri  shoidd  be  consdnil/i/ 
under  the  control  of  an  assistant.  The  trunk,  as  it  emer<;es, 
should  be  suj)ported,  so  as  to  prevent  undue  strain  upon  the 
perineum  and  traction  upon  the  after-coming  head.  As  soon 
as  the  feet  apj)ear  the  le^s  may  be  gently  drawn  down  in  su<'h 
a  wav  as  to  make  no  traction  upon  the  bodv  of  the  child. 

As  soon  as  the  umbilicus  comes  within  reach  of  the  fm^'cr, 
a  loop  of  cord  may  be  ^ontly  drawn  down  and  examined.  If 
it  is  j)ulsarin^  well,  the  case  may  be  allowed  to  deliver  slowly  ; 
hilt  should  there  be  evidence  of  compression  upon  it,  then  the 
<lclivered  portion  of  the  child's  body  should  be  pressed  ba<dv- 
ward  and  upward,  and  an  attemj)t  niade  to  loosen  the  cord 
an<l  to  place  it  in  one  or  other  iliac  fossa  out  of  harm's  way  ; 
if  this  effort  fails,  then  delivery  should  be  accomplished  as 
speedily  as  possible. 

As  the  elbows  appear  at  the  vulva  the  arms  should  be 
drawn  down,  and  then  the  child's  body  should  be  well  ele- 
vated, so  as  to  prevent  the  escape  of  the  head. 

In  the  delivery  of  the  head  there  is  no  need  for  ra])idity  in 
normal  cases,  when  once  the  mouth  and  nostrils  have  cleared 
tlic  perineum.  These  must  be  wiped  off  to  ]>revent  aspira- 
tion of  mucus  should  the  child  attempt  to  breathe.  Then  the 
head  should  be  delivered  slowly  and  carefully,  so  as  to  avoid 
ruj)turing  the  perineum. 


22« 


PATUOLOdY  OF  LAliOR. 


Treatment  of  Arrest  of  Breech  at  the  Brim. 

Arrest  of  the  breech  at  the  brim  immv  he  due  to  tin-  cxccssiNc 
size  of  tlic  <'liil(l  or  to  pclvicr  dcfoniiity.  'I'lic  jH'ccniitiiii 
should  idwiiys  he  taken  of  incasiiriiijr  the  inollicr's  pclxi-. 
uidoss  tlii.s  lias  boon  done,  bef'oiv  any  o}){'rativ('  nicasMrcs  ;iii 
atlo|»t('d. 

'I\)  srcnrc  descent  five  methods  are  available:  (1)  l,\ 
l)rin<ijin^  down  the  anteiM(»r  let::;  (-)  traction  with  a  linger  in 
the  ^roin  ;  (."»)  the  blunt  hooU  ;  (4)  the  lillet ;  and  (•'))  apiili- 
cation  of  Ibreeps. 

Traction  after  bringing  down  a  leg:  The  hand,  the  ])alni  <it" 
which  eoiTes|)on(ls  to  the  abdominal  as[)ect  of  the  ehUd,  is 


Fi(i,  77. 


Breech  prcsontiitinn— lejjs  extended. 


slowly  introduced  in  the  uterus,  care  bein^  taken  to  ascertain 
the  position  of  the  f<etal  cord  so  as  to  avoid  (Iraijgins:  it  down. 
It  is  well  also  to  ])ress  ii:ently  back  the  breech,  so  as  to  'li>- 
cnga<»:e  it  from  the  brim  befon;  seizing;  a  foot.  The  antcTJj^ 
foot  should  always  be  selected,  and  when  firmly  grasped  may 


M.\S.\(;rMl':ST()F  LMKUl  IS  ItllEECll  PllEShSTATIOSS.  225) 


l.r  "rciitlv  (Irawii  tliroiit'li  tlic  os  mid  vniiiiia.  <  )cfa>itmallv  the 
IrM's  may  l)c  liumd  extended  aloiij;'  the  clicst  <»f  tin'  cliild  ( l^'ij;. 
77).  Ill  siu'li  a  case  tlio  i'oot  iiiav  hv  \)Vo\\\A\{  witliiii  rcacli  l)V 
|iassin<;  two  liiij^crs  al«»n<;  the  liack  oi'  \\\v  tlii^li,  at  the  sanu; 
tiiiic  abdiictinjjr  it  .<()  as  to  press  tlic  kiu'c  to  one  side;  tims  tlio 
loot  tends  lo  di-o))  down  in  tii(>  median  line  oi'  the  eliest,  and 
may  be  grasped  by  sli|)|)inp:  th(;  lingers  down  alon^  tlie  le^. 
I'rovideii  there  are  no  iiulieations  neeessitatin^  speedy  (hdivery, 
!  lie  ease  may  be  left  to  natnre  as  soon  as  the  foot  has  been 
(liMwn  down  to  the  vnlva. 

Siiotdd  the  patient  be  exhansted.  delivery  may  be  hastened 
liv  eombined  traetit)non  the  foot  which  has  been  bron^ht  down, 
and  pressure  on  the  fundus  from  above.  The  latter  slionld  be 
managed  by  the  assistant,  so  that  the  operatoi-  may  ^ive  his 
whole  attention  to  the  child.  When  it  is  <lesire(l  to  eifect  a 
.-.pcedy  delivery  the  patient  should  be  placed  in  the  W'alcher 
|iiisition,  and  when  possible  on  a  table.  The  foot  should  bo 
Liiasped  between  the  first  and  second  fm^ci-s,  and  the  line 
of  traction  sliould  be  downward  and  backward  in  the  axis 
nf  the  ])elvio  brim,  ^^']len  the  Ic^  is  beyond  the  vulva  it 
>hoMld  1)0  wraj>ped  in  a  warm  sterile  towel,  and  then  as  much 
(if  the  limb  as  [)()ssible  slioidtl  be  orasjied  in  the  whole  hand. 
The  ojH'rator  should  introduce  the  forelin^'cr  of  his  free  hand 
into  the  vay^ina  and  hook  it  into  the  ])osterior  ^roin  as  soon  as 
it  comes  within  reach,  in  order  to  distribute  the  tractive  force 
iH  widely  as  possible,  and  thus  reduce  the  risks  of  injury  to 
tlic  child.  As  the  breocli  distends  the  perineum  it  should  bo 
(hawn  forward  against  tlio  ))id)es,  so  as  to  avoid  laceration. 
A-  soon  as  ]>ossil)le  the  posterior  limb  should  be  gently  drawn 
tMit,  in  doing  this,  pressure  on  the  thigli  should  be  avoided, 
care  being  taken  to  seize  the  foot  and  draw  down  tlio  leg  in 
such  a  way  that  the  knee  comes  down  in  the  median  line  of 
tile  child's  bodv. 

W  hen  it  is  impossible  to  bring  down  a  foot  it  may  be  pos- 
sil)le  to  hook  the  forefinger  in  the  groin,  which  may  be  done  in 
iniy  manner  convenient  to  the  o])erator.  Traction  may  then 
lit'  made  downward  and  backward,  care  being  taken  to  avoid 
jiH'ssure  on  the  shaft  of  the  femur,  on  account  of  tlie  danger 
of  its  snapping. 

rhe  blunt  hook  or  fillet  may  be  used  as  a  tractor.    Tlie  latter 


230 


PATHOLOGY   OF  LAliOJi. 


yliould  Ik!  ii.s(!(l  l)y  prelViviiee  as  imicli  U'ss  liable  to  do  damage 
to  mother  or  child. 

TIk;  fillet  is  usually  couiposed  of  a  strij)  of  stcrili/cd  cotton 
or  ^au/c  haiida^^c.  The  hcst  iiistnuiicut  lor  plaiMut;  tiiu  lilici 
is  a  ^uni  clastic!  catheter.  The  catheter  should  he  thread*  d 
with  a  loop  of  striujjj  and  then,  with  its  stihft,  should  he  hent 
so  as  to  form  a  lar^e  hook.  After  it  has  heen  sterilized  tin- 
hook  should  he  guided  over  the  anterior  hip  and  rotated  .-u 
that  its  point  |)asses  between  the  child's  thif^h  and  alxlotneii. 
The  finder  should  then  he  passed  between  the  thighs,  and  tlir 
loop  of  striiifi^  dra<;^e(l  <lown  until  the  fdlet  can  be  threaded 
through  it,  when  by  withdrawing  the  catheter  and  strint:  tlic 
fillet  can  be  drawn  into  ])lace.  The  line  of  traction  should 
then  be  toward  the  child's  sacrum,  so  as  to  avoid  breaking  the 
femur. 

As  a  last  resort,  shoidd  all  other  means  fail,  the  forceps 
should  be  applied  to  the  breech. 


Impaction  in  the  Pelvic  Cavity. 

When  the  breech  becomes  impacted  in  the  pelvic  cavity  (Fig. 
78)  it  is  generally  impossible  to  draw  down  a  leg. 

Traction  mtiy  be  exerted  by  hooking  an  index-finger  into 
the  groin  ;  or  the  fillet  may  be  used.  AVhen  these  means  fail 
forceps  may  be  em|)loyed.  If  the  child  is  alive  and  moderate 
traction  with  the  forceps  fails,  then  symjdiysiotomy  may  !»(• 
resorted  to.  When  the  child  has  perished  embryotomy  is 
necessary. 

Rapid  Extraction  of  the  Trunk. 

As  soon  as  the  legs  and  the  pelvis  of  the  child  have  escaped 
from  the  vulva  they  shoidd  be  wrai)ped  in  a  warm  towel  luid 
grasj)ed  with  both  hands  in  such  a  way  that  the  thumbs  of  the 
o])erator  lie  along  the  sacrum,  while  the  fingers  seize  tli(> 
thighs.  This  gives  the  most  secure  grasp.  Tracticm  is  then 
made  downward  and  backward  with  both  hands,  while  the 
assistant  presses  firmly  on  the  fundus.  As  soon  as  the  cord 
can  be  reached  a  looj)  should  be  drawn  down,  as  is  done  in 
normal  delivery  of  the  breech. 

When  the  angles  of  the  scapulae  come  into  view  the  delivery 


M^NAaKM^:^T of  lauoh  is  unEEcii  viiESEyvATioMi.  2:U 

(.f  the  arms  slioiiM  Ik;  attcmpti'd.  To  tlo  this,  two  liiif^ers  of 
tlio  ojM'rator's  hand  which  coiicsjhiikIs  to  tlic  arm  it  is  di'sircd 
t(»  roacli,  should  Ix'  passed  n[)  over  the  shouhlri*  and  (h)wn  the 
arm  to  the  elbow,  wliicii  may  then  he  swept  aeross  the  chest 
>.()  jis  to  l>rin^  (h)Wii  tiie  forearm  and  hand,  the  chihl's  hody 
being  luild  in  such  a  position  as  to  give  \\w  greatest  freedom 

Fio.  78. 


Delivery  of  child  in  a  breech  case  by  traction  made  with  fingers  placed  in  groin. 

(After  A.  R.  Simpson.) 


of  movement  possible  to  the  operator.  Having  released  one 
arm,  the  operator  should  then  change  hands  and  deliver  the 
other  arm  by  a  similar  manwuvre. 

Upward  displacement  of  the  arms :  Not  infrequently  the 
arms  are  found  to  be  displaced  upward  alongside  the  head. 
This  is  generally  indicated  by  greater  resistance  to  traction 


232  PATIIOLOGY  OF  LABOR. 

after  the  scajmhe  have  wmie  into  view.  Wlien  this  coniplicii- 
tion  is  found  the  body  of  the  fo'tus  should  be  [)usiied  uj)  i 
the  axis  of  the  brim,  so  as  to  diminish  the  pressure  on  th. 
arms  at  tliat  level.  The  body  should  then  be  rotateil  until  it- 
back  is  directed  to  one  or  other  side  of  the  mother.  Usuall 
the  posterior  arm  is  most  accessible,  and  is  therefor  j  bronchi 
down  first.  Holding  the  child's  body  up  against  the  pubt  ■ 
the  operator  presses  two  fingers  up  over  the  posterior  should*  !• 
to  the  elbow,  and  sweeps  the  arm  down  across  t!:e  face  ami 
chest,  as  directed  above.  Having  released  the  posterior  arm. 
the  child's  body  is  pressed  over  against  the  perineum,  and  tli" 
anterior  arm  is  brought  down  by  a  similar  maufeuvre. 

The  anterior  arm  may  be  so  firmly  caught  between  the  heal 
and  the  pubes  *hat  it  may  be  impossible  to  dislodge  it.  In 
this  case  it  should  be  rotated  so  as  to  come  into  a  posterior 
position.  This  rotation  is  accomplished  by  grasj)ing  the  trunlc 
of  the  child's  body  firndy  with  both  hands,  lowering  it  so  as  in 
bring  its  long  axis  to  correspond  to  that  of  the  pelvic  brim, 
and  then  shoving  it  up  so  as  to  release  the  anterior  arm  from 
pressure.  As  soon  as  the  arm  is  loose  alongside  of  the  head, 
the  child  is  rotated  about  its  long  axis,  so  that  the  arm  wliicli 
has  been  anterior  passes  along  the  same  side  of  the  pelvis 
backward  and  rests  in  front  of  the  sacro-iliijc  synchondrosis. 
By  this  manipulation  the  back  is  moved  from  one  side  to  tlic 
front,  and  then  to  the  opposite  side.  Tlie  arm  is  then  deliv- 
ered as  was  the  posterior  arm  in  the  first  instance.  Occasion- 
ally the  anterior  arm  may  be  folded  behind  the  occiput.  In 
this  case  the  revolution  of  the  body  must  be  made  in  the 
opposite  direction.  First  turn  the  abdomen  of  the  child  for- 
ward and  then  to  the  opposite  side,  thus  causing  the  shoulder 
to  rotate  through  three-quarters  of  a  circle. 

Constriction  of  the  head  by  the  cervix :  Occasionally  the 
cervix  may  become  tightly  constrictt  ^  about  the  child's  neck  ; 
a  condition  which  generally  endangers  the  life  of  the  child. 
The  patient  should  be  deeply  anaesthetized,  and  traction  made 
on  the  shoulders  with  one  hand,  while  the  fingers  of  the 
other,  placed  in  the  child's  mouth,  give  what  assistance  is 
possible. 


I 


ilASAdEMl'JST  OF  LA  Unit  fX  liltEEi'lI  PRKSKSTATloys.  2.33 


Delivery  of  the  After- coming  Head. 

Deventer's  method :  IVobably  the  oasicst  nu'tliod  of  ctlwt- 
iu\r  a  speedy  delivery  in  a  ease  in  wliich  the  pelvis  permits  tiie 
descent  of  tiie  iiead  with  the  arms  extended  alongside  is 
Ih'irnter^s.  Tiie  body  of  the  ehiUl  is  dropped  downward, 
ihe  feet  are  grasjjed  witii  one  iian<l,  wiiile  tii(!  other  presses 
upon  tlie  upper  surfaee  of  the  siiouhlers,  the  neelv  being  be- 
tween tile  first  and  second  fingers.  Traction  is  made  downward 
toward  tlie  floor,  the  patient  being  in  the  lithotomy  position. 

Fig.  79. 


Anterior  rotation  of  opcipiit. 

Thus  the  occiput  appears  at  tlie  vulva,  the  vortex  slips  under 
the  j)elvic  arch,  and  the  head  is  delivered  in  extension,  being 
followed  by  the  arms.  This  method  is  applicable  only  in  cases 
ill  which  the  pelvic  space  is  sufficient  to  permit  the  descent 
of  the  head  and  arms  together.  When  the  fo'tus  is  small,  as 
in  premature  cases,  this,  in  the  experience  of  the  writer,  is 
the  easiest  and  most  ra])id  method  of  delivery.  Contrary  to 
expectation,  laceration  of  the  perineum  is  rare  in  cases  in 
which  this  method  of  delivery  is  possible. 


234 


PATHOLOGY  OF  LABOR 


Arms  Delivered — Head  Still  Retained. 

Having  delivorod  the  arms,  tlio  head  boing  still  retaiiuii 
the  operator  has  five  methods  ot"  delivery  at  his  disposal. 

1.  The  Smellie  method:  The  body  of  the  ehMd  iiaving  been 
\vrap})ed  in  a  warm  towel,  is  plaeed  on  the  flexor  snrface  of 
the  operator's  left  arm,  the  legs  hanging  on  either  side.  The 
fingers  of  this  hand  are  passed  into  tlie  vagina,  so  that  tin 

Fio.  80. 


The  Smellie-Veit  method  of  extracting  the  after-coming  head.    (DiJderlein.) 

tips  rest  on  the  fossa  on  either  side  of  the  child's  nose.  Tlir 
finger-tips  of  the  right  hand  are  then  j)laced  on  the  ehild's 
occiput.  Before  making  efforts  at  extraction  the  head  is 
well  flexed  by  pushing  upward  with  the  fingers  on  the  occiput, 
and  at  the  same  time  pulling  down  with  the  fingers  on  tlio 
face.  Having  secured  good  flexion,  the  operator  pulls  down- 
ward until  the  occiput  is  well  under  the  pubic  arch  (Fig.  7JM, 
and  then,  but  not  till  then,  the  trunk  is  raised,  at  the  smmk 
time  that  traction  is  ma<le  so  as  to  pivot  the  occiput  under 


MASAGEMEyT  OF  LABOR  IN  liRKEClI  PRESKNTATIOSS.  235 

the  pubic  arcli,  and  thus  tlio  face  sweeps  over  tlie  perineum 
;uul  the  liead  is  delivered.  Care  nnist  be  exerted  not  to  make 
ti action  with  any  deuree  of  force  once  the  head  distends  tlie 
perineum,  otlierwise  the  head  will  deliver  with  a  snap  and 
the  result  will  probably  be  an  extensive  laceration. 

2.  The  Smellie-Veit  or  Mauriceau  method:  The  child's  body 
is  placed  on  the  operator's  arm  as  described  above,  but  one  or 
two  finders  are  inserted  into  the  mouth  instead  of  ou  either 
,~i(le  of  the  nose.  The  other  hand  is  passed  alon^  the  child's 
hack  until  the  middle  finger  rests  on  the  occipital  protuber- 
ance, while  the  index  and  ring  fingers  are  Hexed  over  the 

Fig.  81. 


The  Wigand-Martin  method  of  delivering  the  after-coming  head.    (Diiderlein.) 

shoulders  on  either  side  of  the  neck  (Fig.  80).  Having 
loosened  the  head  and  secured  good  flexion,  traction  is  then 
made  with  both  hands  at  once,  in  tiie  axis  of  the  pelvic  out- 
let, until  the  occiput  pivots  under  the  pubes  ;  then  the  child's 
hody  is  carried  upward  toward  the  mother's  abdomen,  this 
movement  beinjx  made  verv  slowlv  and  deliberatelv,  to  avoid 
laceration  of  the  perineum.  Care  must  be  taken  not  to  fract- 
ure or  dislocate  the  lower  jaw. 


2;JG 


PATIWIJHIY  OF  LABOR. 


3.  Wigand-Martin  method:  The  cliild's  Ixxly  is  held  on  tin; 
lelt  arm,  the  iiidex-Hnger  of  the  h'f't  hand  Ix'ing  inserted  iiii. 
tlie  mouth  in  order  to  Hex  the  head.  Tlie  right  liand  is  thi  n 
phieed  on    tlie    mother's  abdomen  over    the   puhes,  so  as    m 

seenre  a   firm  grasp  of  the  he    I 
Fio.  82.  (^  JJ^-  ^l)'      Firm  pressure  is  \.\\<  n 

made  with  the  right  hand  in  tiic 
axis  of  the  parturient  eanal  ;  a 
the  same  time  traction  is  ma^ic 
with  the  left  hand,  and  as  the 
head  descends  the  child's  body  is 
elevated  toward  the  mother's  ait- 
domen. 


4.  Prague  method :  Having  wr; 


III- 


])ed  the  body  in  a  warm  towel,  ilic 
operator  seizes  the  child's  feet  with 
the  right  hand,  the  middle  finp  r 
being  placed  between  the  internal 
malleoli,  the  index  and  ring  ting(  is 
being  above  the  external  mallenlj. 
The  left  hand  is  then  placed  on  ilic 
child's  shoulders  in  such  a  way  a- 
to  seenre  a  firm  grasp  (Fig.  ^>-). 
Flexion  is  then  made  downward 
irWi  both  Jiands  until  the  oc(*ij)iit 
appears  under  the  pnbes.  Th(  ii 
the  right  hand  swings  the  bodv 
upward,  at  the  same  time  makiiiir 
traction,  while  the  left  hand  is  held 
firmly  in  position,  being  used  as  a 
fulcrum  around  whicli  the  lieail 
moves,  until  it  is  finally  forced 
otit  of  the  parturient  canal  by 
this  lever-like  movement  of  the 
body. 

The  force  exerted  by  this  metlnxl 

is  very  considerable,  and  therefore  it  shoidd  be  used  only  af(<  r 

the  foregoing  methods  have  been  attemj)ted. 

5.  Forceps :  Manual  efforts  at  extraction  having  failed,  the 

forceps  may  be  used.     To  permit  the  application  of  the  blades, 


Prague  grasp. 


TRAXSVKfiSI':  PRI'JSESTATroXS.  237 

I 'ir  child's  licad  must  Ix' held  up  toward  the  motlicr's  jilulo- 
ii  (11  l)y  an  assistant.  Properly  diivctcil  suprapul)i('  j)r(>ssure 
h\  an  assistant  incivascs  the  I'llicacv  of  al!  nu'tliods  ot"  di'Iiv- 
(  linu:  tlie  aftoi'-coining  head.  Six  minutes  is  the  maximum 
time  at  tiie  operator's  dis|)osal  onee  tlie  placental  eireulation 
Ills  heen  completely  cut  oiV.  Therefore  it  is  advisable  to  have 
tlie  assistant  call  oif  the  minutes  as  the  time  |)asses,  so  that 
liie  last  two  may  be  utilized  for  the  application  of  the  f()rce|»> 
>hould  recourse  to  these  instruments  l)e  re(iuired. 

TR AN8 VE RS E   Pli ES ENT ATIONS. 

Definition:  Any  presentation  of  the  trunk  of  the  child's 
liiidy  is  termed  a  transverse  presentation.  As  the  result  of 
uterine  action  after  the  onset  of  labor  transverse  presenta- 
tions resolve  into  shou/dcr  ^>yc.vcH/(f//oy<.s-.  The  term  c/'o.s.s- 
hirf/i  is  frecpiently  apj)lied  to  a  transverse  presentation. 

Frequency:  Less  than  0.5  per  cent,  of  all  cases  of  labor 
l»i\'si'nt  transverse  j»resentations. 

Causes:  The  same  causes  that  residt  in  breech  j)resentations 
iilso  act  in  producintz:  transverse  presentations. 

Varieties :  The  lon^  axis  of  the  trunk  is  very  rarely  trans- 
Vvi'se,  but  is  usually  obliijuely  placed  as  re<2:ards  the  lonji:  axis 
of  the  uterus;  thus  any  part  of  the  f<etus  may  present  at  the 
liriin. 

Positions:  Some  writers  classify  transverse  presentations 
lu'cording  to  the  position  of  the  lowest  shouhkn',  making  use 
(if  the  scapula  as  the  denominator;  c.  r/.,  S.  Ij.  A. ;  S.  K.  P., 
etc.  It  is  generally  sufficient  to  classify  the  positions  as 
follows : 

1 .  Do)'Ho-anfc)'lor : 

(a)  Head  on  the  right  side  of  mother. 
(6)  Head  on  left  side  (Fig.  83). 

2.  Dorsopoxtcrioi' : 

(<i)  Head  on  right  side. 
(6)  Head  on  left  side. 
The  mod  frequent  posithm   is  dorso-anterior,   head  to  the 
rii;ht  side  of  the  mother. 


238 


PATIIOLOar  OF  LABOR 


Diagnosis  of  Transverse  Presentations. 

Abdominal  examination:  On  inspection  the  shape  of  tiic 
ntcrine  tnnior  will  be  noticed  to  he  ahnornial.  Ihv  Ion;:,  -i 
diameter,  instead  of  being  vertical,  will  be  found  to  be  obliijiic, 

Fig.  83. 


Transverse  presentation.    Dorso-anterior,  head  on  left  side,  arm  prolapsed. 

( FaraVjon  f . ) 

or  even  transver.se.  '^Phe  head  will  generally  be  found  in  «»iio 
or  other  iliac  fossa,  while  it  is  impossible  to  explore  the  jxlvic 
excavation  from  above,  for  the  trunk,  as  a  rule,  coniplct*  ly 
fills  the  false  pelvis.     If  the  back  is  to  the  front,  its  smooth 


MECHANISM  OF  TRAySVKRSE  PRESESTATIOyS.    231) 

surface  can  bo  felt  across  the  lower  /one  of  the  mother's  alxlo- 
incn.  If  the  back  is  directed  posteriorly,  the  fo'tal  limbs  can 
he  felt  in  front.  The  fietal  iK'art-sounds  arc  heard  l)elo\v  tiie 
iiiiibilicus,  plainly  when  the  back  is  to  the  front;  faintly,  if  at 
ali.  when  the  limbs  are  anterior. 

Vaginal  examination:  If  the  memi)ranes  are  niiriij)tured,  no 
|);irt  of  the  fietns  can  be  reached  by  the  examinin<;  fm^er 
without  jiTcat  <lit!icnlty.  Occasionally  a  limb  or  tho  prolapsed 
(•(.nl  mav  b(!  felt  within  the  ba^  of  waters.  When  the  mem- 
hiaiics  have  ruptured  the  Hn<^er  may  come  in  contact  with  an 
arm  or  the  shoulder.  The  landmarks  to  be  felt  are  the  clav- 
icle, the  humerus,  and  the  spine  of  the  scapula.  The  Hntrer  may 
he  forced  into  the  axilla  and  the  ribs  felt,  thus  distinguishiu<; 
it  from  the  ^roin.  Very  frecpiently  in  transverse  presen- 
tations a  hand  is  found  prolapsed,  which  hand  it  is  being 
distinguished  by  shaking  hands  with  it. 

Prognosis. 

As  spontaneous  delivery  is  very  rare  in  transverse  presen- 
tations, the  prognosis  in  cases  left  to  Nature  is  very  grave, 
both  for  the  mother  and  the  child.  As  artificial  delivery  is 
the  rule  in  these  cases,  the  prognosis  depends  on  the  length 
of  time  the  case  has  been  allowed  to  go  on  without  treat- 
ment and  the  nature  of  the  operative  interference. 

The  dangers  to  the  mother  are  exhaustion,  ruj)ture  of  the 
uterus  from  thinriing  out  of  the  lower  uterine  segment,  risks 
of  operative  interference  and  of  subsequent  sepsis. 


Mechanism  of  Transverse  Presentations. 

As  a  rule,  natural  delivery  is  impossible  in  transverse  pres- 
entations, but  in  extremely  rare  instances  Nature  may  elfect 
delivery  by  one  of  three  methods : 

1.  Spontaneous  version :  [Jterine  contractions  may  result  in 
displacement  of  the  foetus  and  its  gradual  version,  so  that  its 
long  axis  finally  corresponds  to  the  long  axis  of  the  uterus. 
Thus  the  transverse  ]>resentation  becomes  altered  to  that  (►f 
the  breech  or  the  head,  the  delivery  then  taking  place  accord- 
ing to  the  new  presentation,     S})ontaneous  version  may  take 


240 


rATllOLOGY  OF  LABOR. 


))l;i('e  before  or  after  rupture  of  the  menihraues,  and  is  wv, 
likely  to  oceur  in  multipara!  and  wlien  the  ehild  is  livinj:. 

2.  Spontaneous  evolution:    This  nieehanisui   is  favored 
ex(.'essively  strong  uterine  eoutiaetions,  a  roomy  pelvis,  am: 
small  fcetus. 

By  the  strouj^  uterine  contractions  the  anterior  shoiddci 
forced  down  into  the  pelvis,  and  rotates  to  the  front,  while  i 
head  lies  ahove  the  brim  and  over  the  puhes  ;  the  breech  :i; 
truidi  ar(!  then  compressed,  and   gradually  forced    jKi-t    i 
head  and  anterior  shoulder,  which  pivots  on  the  j)ul>ic  air 

Fio.   84. 


ro 


IS 
IC 

1(1 

IC 

ll. 


Spontaneous  evolution.    First  stage. 

Thus  the  chest  and  breech  slip  ])ast  the  shoulder,  over  tlio 
perineum,  and  are  delivered.  Finally  the  head  enters  the  p(  1- 
vis  and  rotates,  so  that  the  occiput  pivots  under  the  pubic  nidi 
and  the  face  sweeps  over  the  perineum,  thus  completinsr  the 
delivery  (Figs.  84-88). 

3.  Delivery  with  the  body  doubled  up  {Kvolntlo  con  (Jup/i'-'it'i 
corpore) :  The  conditions  favoring  this  mechanism  are  stioiig 


I 


MECHANISM  OF  TRANSVERSE  PRESENTATIONS.    241 

Ki(i.  85. 


Spontaneous  evolution.    Second  stage. 
Fig.  86. 


-|Mintiiir.'ous  evolution.    Third  stage. 


]6-0b.-t 


242 


PATHOLOGY  OF  LABOR. 
Fio.  87. 


Spontam-ons  evolution.    Fifth  stnpc. 


MECIIAMSM   OF  TRASSVEnsE  rilESESTATlOSS.    'l\'^ 

utciino  contractions,  a  roomy  jxlvis,  an«l  a  small  dca*!  fo'tiis. 
1'lie  presenting  HJiouUler  is  (Irivcn  down  into  the  pelvis  and  is 

Via.  89. 


Hirtli  of  child  doublcrl.    Kvnlutio  con  cluplicato  onrporo.    (Klcinwiirhtor.) 


(lolivored  first,  tlie  head  and  ehest  of  the  fo'tus  are  eom])ressed 
tnsrctlier  and  forced  throuii^li  the  eanal,  being  tiius  delivered, 
ami  are  followed  by  the  breech  and  legs  (Fig.  89). 


2M  I'ATiioLoay  of  lajwr. 

Management. 

'I'raiisvcrsc  prcsciitatioiiK  should  never  he  h'ft  to  Nntiir.  to 
<h'liver.  If  seen  early  and  tlie  iu-tus  is  alive,  version  >h(iiil(| 
he  |)erlornie(l. 

It'  seen  late,  when  inij)aeti<)n  has  taken  place  an<l  the  I'o  tiis 
lias  perished,  then,  if  version  cainiot  he  easily  perforuird, 
decapitation  and  evisceration  should  he  done,  so  as  to  rediKr 
the  risk  to  tiie  mother  to  the  smallest  po.ssihle  limit. 


niOLAPSE  OF  THE  FCETAL   LIMBS. 

In  Head  Presentations. 

Any  or  all  of  the  f<etal  extremities  may  prolapse  alon^r-.i(|o 
the  head. 

The  most  common  form  of  this  accident  is  a  prolapse  (if  ;i 
hand,  which,  when  it  occurs,  is  found  elos(!  to  the  tempi  nil 
region.  The  worst  form  is  when  an  arm  lies  across  the  hack 
of  the  neck. 

Treatment. 

If  the  condition  is  discovered  before  the  rupture  of  tlic 
memhranes,  an  attempt  should  he  made  to  overcome  the  ditli- 
cn\iy  hy  poxf lira/  ftr<tf)ii(nf.  The  wojnan  should  lie  on  tlir 
side  opponifc  the  prolapsed  extremity,  with  the  hips  sliulitly 
elevated. 

After  tlic  membranes  have  ruptured  an  attempt  should  lie 
made  to  dislodge  and  ])ush  up  the  prolapsed  extremity.  Td 
'^o  this  the  woman  should  he  placed  as  recommended  aiiovc 
iliould  the  attempt  fail  ihc  forccj^s  may  be  applied,  care  hciiiu 
taken  to  avoid  in<'lnding  the  hand  in  the  gras])  of  the  hhnlc-. 
and  the  head  drawn  down  to  the  outlet.  This  very  ditcii 
causes  the  arm  to  slip  up  out  of  the  way.  Should  it  be  IimiikI 
impossible  to  dislodge  the  arm  sufficiently  to  apply  the  foivcj)-. 
vcrfo'on  may  be  carried  out. 

When  the  condition  is  not  discovored  till  the  head  is  low 
down  in  the  cavity,  the  forceps  should  be  applied  and  the  caw 
terminated  as  ra})idly  as  is  possible. 


TWIN  LAIiOliS.  215 

In  Breech  Presentations. 

TIh!  prolapse  (►!'  tlii'  liaiul  is  of  no  iiii|>ortaiic('  in  bivccli 
pi'i'.senlutions,  ami  no  attention  net'(l  be  paid  to  it. 

In  Transverse  Presentations. 

Tlic  prola|)se  of  a  foot  is,  of  course,  favoral)le. 

Sliniild  a  hand  or  arm  be  found  prolapsed,  il'  it  cannot  be 
|iii-;li('d  up  out  of  the  way,  it  may  be  tlrawn  down  snllieiently 
|m  fasten  a  broad  piec^e  of  tape  about  the  wrist.  After  version 
111-  been  performed  the  tape  may  be  lu'ld  so  as  to  j)revent  the 
;irm  from  rising  alongside  the  head  and  ('om|)lieating  its 
descent. 

PLURAL   BIRTHS. 

Twin  Labors. 

These  are  usually  easy  and  uncomplicated. 

Twin  pregnancy  occurs  about  once  in  l.">()  cases  of  gesta- 
tion ;  while  triplets  occur  about  once  in  5088  cases. 

The  tendency  to  twin  pregnancy  is  very  frecpiently  Jicirdi- 
Itii-jl.    The  greatest  number  of  reported  cases  have  occurred  in 

According  to  the  origin  of  the  ova  will  arise  the  various 
peculiarities  in  the  development  of  the  placenta'  and  mem- 
hr.ines. 

If  the  two  ova  have  bee'/  derived  from  separate  Graidian 
follicles,  each  will  have  its  own  |)lacenta,  cord,  chorion,  and 
amnion,  eairh  being  in(i(  pendent  of  the  other. 

Sjiould  the  two  ova  have  been  derived  from  a  single 
(iraafian  follicle,  the  amniotic  sacs  will  be  distinct,  but  the 
choricm  and  phu'enta  will  be  in  common,  the  two  cords  aris- 
iiiu"  from  the  same  placenta. 

I  sually  twins  arising  from  ova  fiom  a  single  (Jraafian 
fi»llic!e,  are  of  the  same  sex  ;  while  when  the  original  ova 
are  distinct  each  is  of  an  opj>osite  sex.  3Iii/e  twins  are 
slightly  more  common  than  female  twins. 

Diagnosis:  Very  frecpiently  the  diagnosis  of  twins  is  not 
made  until  after  the  birth  of  the  first  child.    The  oidy  ccrtuhi 


246  PATHOLOGY  OF  LABOR. 

signs  of  twin  pregnancy  are  tlic  presence  of  two  f(x?tal  lioar!- 
sounds,  lieard  at  dittereiit  ])()ints  over  the  alxloniiiial  snrl':i<  !•, 
and  liavin<j^  a  different  rhythm  ;  and  the  palpation  of  two  dis- 
tinct lieads. 

Other  Hiffnn  are.  excessive  size  of  the  ab(h)men,  witli  in- 
creased uterine  distention,  irre<^ularity  of  the  uterine  onthnc, 
and  the  presence  of  a  number  of  fu^tal  extremities. 

Prognosis  :  The  mf^^/ovu// prognosis  is  somewhat  graver  tlim 
in  single  births.  Tiie  <ii(n<jcrti  are  :  ttterinc  inertia  due  ii> 
overdistention  of  the  uterine  walls;  dbnormal  prexentntion  ; 
ulbaminurid  and  ecUwip.sitt,  more  fre(|uent  in  j)lural  |)r(  te- 
nancies;  Jiemorrhaxje  in  the  third  stage  of  labor  from  tnMil)l(' 
in  the  delivery  of  the  placenta. 

The  fd'tdl  pro(/n<),si.s  is  always  more  serious  tlian  in  simple 
births.  The  ddiif/er.s  are  :  deficient  develo})njent  from  ovri- 
crowding  in  the  uterus;  via  Ijmj-s  it  ion  dnd  nidlprefientdtion ; 
and  hydranitiios. 

Mechanism:  The  following  table  from  Spi"gelberg,  bastd 
on  1138  lab.trsj  gives  the  combined  presentations  in  tin  ir 
order  of  frequency. 

Both  heads  presenting 40.00  per  cent. 

Head  andhreech 31.70 

Koth  pelvic  presentations 8.00         " 

Head  and  transverse      G.18         " 

Breech  and  transverse 4.14        " 

Both  transverse 0.37        " 

The  order  of  de/ireri/  varies.  When  both  heads  present, 
usually  the  larger  is  delivered  first.  If  one  twin  presents  by 
the  breech  and  the  other  by  the  head,  usually  the  latter  is 
delivered  first ;  if  one  presents  transversely  and  the  other 
longitudinally,  the  latter  is  usually  expelled  first. 

Management  of  labor:  AVhen  the  presentation  of  the  liist 
child  is  normal  no  sj^ocial  treatment  is  indicated.  AVhen  the 
first  child  has  been  delivered  and  its  res])iratory  function  well 
established,  before  cutting  the  cord  the  physician  should  pil- 
pate  the  mother's  abdomen  to  ascertain  the  position  of  the 
second  child.  If  any  abnormality  exists,  it  should  be  at  (Hice 
corrected  by  external  manipulations  and  the  fundus  uteri 
gently  kneaded  to  stinudate  retraction.  The  fundus  may  then 
be  placed  in  charge  of  the  nurse  or  assistant  while  the  phy«^i- 


2'U7iV  LABORS.  247 

(ian  attends  to  the  cord  of  tlio  first  cliild.  This  shoidd  be 
tied  in  two  phices  and  then  divided  l)etween  the  ligatures,  in 
case  there  siiould  be  eonniiunication  between  the  phieental 
Iicnlations  and  the  second  chihl  bl(>ed  to  deatli. 

Friction  on  tiie  iunchis  siioukl  be  sustained  until  the  uterine 
lontractions  are  firndy  established.  Jt  is  not  advisable  to 
wait  more  than  halt' an  hour  for  the  birth  of  the  second  chihl. 
Tiie  second  amniotic  sac  shouhl  then  be  ru|>tured  and  the 
uterine  contractions  reinforced  by  firm  pressure  on  the  i'undus 
so  as  to  expedite  the  delivei-y  oi'  the  second  child. 

From  this  time  until  retraction  has  been  firmly  established, 
after  the  complete  emptying;  of  the  uterus,  the  fundus  shouhl 
b(  kept  constantly  under  control  in  order  to  ])revcnt  its  relax- 
ation and  the  occurrence  of  hemorrhage. 

Should  hemorrhage  follow  the  delivery  of  the  first  child, 
the  sect»nd  should  be  delivered  as  rajiidiy  as  ])ossil)le,  either 
by  forceps  or  version,  and  the  uterus  emptied  artificially.  It 
is  not  advisable  to  infoi'm  the  mother  during  labor,  shouhl  a 
diagnosis  of  twins  be  established,  as  the  shock  may  iidiibit 
uterine  action. 

Complications  of  Twin  Births. 

Compound  presentations :  Occasionally  both  fietuscs  tend  to 
engage  simultaneously  in  the  brim.  \\  hen  hoflt  liaid.s  tend 
ti»  j)resent  at  the  same  time,  the  highest  should  if  ])ossiblc  be 
]>usiied  uj),  and  the  foi'ceps  then  aj)plied  to  the  lower  head 
and  traction  exerted  until  it  is  firndy  engaged.  During  the 
traction  an  assistant  may  be  able  to  hold  the  hea<l  of"  the  other 
child  out  of  the  way,  by  pressure  on  the  ab(h)nnnal  wall  of 
the  mother. 

When  the  he  id  of  one  child  and  the  breech  of  the  other 
tend  to  engage  at  the  same  time,  the  breech  shoidd  be  j)ushed 
up  and  the  head  <lrawn  down. 

When  fcetal  extremities  are  found  to  |)resent  along  with  a 
head,  they  slu>uld  be  replaced  and  the  head  drawn  down  by 
means  of  the  forceps. 

Interlocking  twins:  Occasionally  both  heads  enter  the 
pelvis,  one  being  generally  well  in  advance  of  the  other.  The 
upper  head  then  becomes  jammed  against  the  neck  and  thorax 
of  the  first  child. 


248  PATHOLOGY  OF  LABOR. 

Trcdtmcid:  The  most  advancod  head  should  l)o  delivend 
by  forcei).s,  as  unlocking  is  generally  out  of  the  question. 
The  second  head  should  then  be  delivered,  and  when  this  i^s 
done  the  Ixxiy  of  the  first  child  may  be  extracted,  the  head 
of  the  second  being  held  out  of  the  way  by  an  assistant. 

Sometimes  it  is  ne(!essary  to  perforate  one  of  the  heads  in 
order  to  permit  the  delivery  of  the  other.  When  this  opera- 
tion is  required  it  should  be  })erformed  on  the  head  of  the  lii-i 
(ihild,  because  the  second  is  more  likely  to  be  alive,  there  beinu; 
less  risk  of  compression  of  its  cord. 

In  cases  in  which  the  breech  of  one  child  and  the  head  of  tlic 
other  become  impacted  in  the  pelvis  an  endeavor  shouKi  he 
made  to  push  up  the  head  and  deliver  the  breech.  The  body 
of  the  child  presenting  by  the  breech  should  only  be  delivered 
as  far  as  the  neck,  as  the  two  heads  u  ually  become  locked  at 
the  brim  by  the  overla|)|)ing  of  the  chins  or  of  the  occiputs,  ur 
by  the  face  of  one  child  being  pressed  against  the  back  of  the 
other  child's  neck. 

Should  it  be  im|)ossible  to  push  back  the  head  of  the  secoiwl 
child  or  to  apply  forceps  and  deliver  it,  the  head  of  the  breech 
child  sliould  be  perforated  and  extracted  before  attempting  to 
deliver  the  other. 

Triplets. 

As  a  rule  no  difficulty  is  encountered  in  the  delivery  of  trip- 
lets, as  the  greater  the  number  of  fietuses  tiie  greater  tlic 
tendency  to  ])rematurity  of  delivery. 

The  labor  is  generally  jM'olonged  on  account  of  delay  in 
the  first  stage  from  imperfect  uterine  contractions. 

The  third  stage  must  be  very  carefully  managed,  and  it  is 
advisal)le  to  empty  the  uterus  artificially  in  order  to  insure 
that  no  portions  of  placenta  are  retained. 

DYSTOCIA   DUE   TO   ANOMALIES    OF   F(ETAL 
DEVELOPMENT. 

Overgrowth  of  the  Foetus. 

Definition :  A  child  may  be  said  to  be  overgrown  when  it 
weighs  eleven  pounds,  or  over,  at  the  time  of  birth.  It  is  but 
very  seldom  that  a  child  is  born  weighing  twelve  pounds;  Imt 


PREMATURE  OSSIFICATION  OF  THE  SKULL.        249 
( uses  are  rceorck-d  in  which  tlie  ])irth-\V('iglit  was  over  twenty 

jMillluls. 

Cause :  Notliinjj^  (lofinito  is  known  as  to  tlic  cause  of 
I  his  overgrowth.  Mnltiparity,  advanced  a»;c  of  one  or  ])otli 
parents,  and  ])roh)nji^ation  of  [)regnancy  are  generally  regarded 
;;-  the  probable  causes. 

Mechanism:  When  the  hea<l  j)resents  in  these  cases  it 
generally  enters  the  ])elvis  in  extreme  flexion.  Monlding  is 
generally  very  marked  as  the  result  of  a  prolonged  second 
stage. 

Treatment. 

The  best  treatment  is  prophylactic.  \\'hen  the  (condition  is 
suspected,  which  is  rare,  a  careful  palpation  should  be  made 
and  the  size  of  the  head  estimated.  The  head  should  then 
Ih!  forced  into  the  brim  by  the  pressure  from  above,  to  give 
one  an  approxinuite  idea  of  the  relative  size  of  tlie  ])elvis.  If 
it  be  found  that  it  is  a  tight  fit,  then  labor  shoidd  be  at  once 
induced,  as  no  advantage  can  be  gained  by  waiting  on  nature. 

When  the  condition  is  not  discovered  until  labor,  then  the 
proper  course  to  pursue  is  to  support  the  patient's  strength 
and  control  the  pains  by  means  of  hypodermics  of  morphine  as 
often  as  required,  until  the  head  has  ha<l  time  to  mould  thor- 
< Highly,  when  forccj)s  may  be  a})plied  and  an  attempt  made  to 
(Icliver  the  child.  Care  should  be  taken  to  avoid  excessive 
force  in   traction. 

If  no  advance  is  made,  and  the  child  is  alive,  .sw/>»y>/< //.s/o/o//<// 
is  then  necessary. 

When  the  condition  is  recognized  early  and  the  disproportion 
hetween  the  head  and  the  ])elvis  is  not  mark(Ml,  iiifcrim/  vcr- 
xinii  mav  offer  the  child  a  ureater  chance  of  life  than  a  hiirh 
forceps  operation.  The  choice  of  operation  dej)ends  in  great 
measure  on  the  skill  of  the  operator  in  j)erforming  the  one  or 
the  other. 

If  the  child  has  ])erished,  iinhryotomji  should  be  the  operation 
of  choice. 

Premature  Ossification  of  the  Skull. 

Premature  ossification  of  the  bones  of  the  skull,  causing 
more  or  less  obliteration  of  the  sutures  and  fontanelles,  greatly 


250  PATHOLOGY  OF  LABOR. 

modifies  the  mouldability  of  tlie  head,  and  may  thus  lead  to 
delay  in  labor. 

Position:  The  liead  may  be  arrested  at  the  brim  or  in  tlic 
cavity. 

Treatment:  Forceps  or  sympliysiotomy  may  be  necessary  to 
secure  delivery  of  a  living  child. 

Hydrocephalus. 

This  is  probably  the  commonest  cause  of  excessive  size  df 
the  foetal   head. 

Etiology:  The  condition  is  due  to  the  (tccHinuhdion  of  tl,, 
Hcrmii  in  the  vcMitricles  of  the  brain.  The  accumulation  (  I" 
fluid  may  be  so  great  as  to  cause  obliteration  of  the  cer(l)r;il 
convolutions  and  excessive  thinning  of  the  cranial  boius, 
which  become  widely  separated.  From  the  excessive  si/c  ol' 
the  vault  the  face  aj)pears  small.  Spina  bifida  or  some  other 
malformation  is  generally  ])resent  in  these  cases. 

Diagnosis :  In  about  a  third  of  all  cases  of  hydroce])haliis 
tlie  breech  presents.  The  condition  should  always  be  sus- 
pected when  in  vertex  ])resentations  the  head  fails  to  engage 
in  the  brim,  although  the  pelvis  is  normal  in  size  and  no 
good   reason  can  be  found  for  the  delay. 

By  (ihdom'mal  examination  the  gaping  fontanelles  ami 
sutures  may  be  made  out  and  fluctuation  may  be  obtained  in 
these  regions.  The  cranial  bones  may  be  felt  to  be  excessively 
thin,  and  })ressure  on  them  may  give  the  sensation  of  crepita- 
tion.    The  head  is  felt  to  be  enlarged  and  soft. 

These  conditions  may  be  better  felt  by  a  bimanual  v.va  mi  na- 
tion when  this  is  possible. 

Prognosis :  The  life  of  the  child  is  to  be  considered  as  of 
little  moment,  for  should  it  survive  birth  death  generally 
takes  ))lace  shortly  after. 

Death  of  the  mother  may  result  from  exhaustion  or  from 
rupture  of  the  uterus.  The  rupture  generally  occurs  in  the 
lower  segment,  which  becomes  greatly  stretched  and  thinned. 

Treatment:  When  the  head  prcxcnfx  (Fig.  90),  it  should  be 
perforated  and  the  fluid  permitted  to  drain  away.  When  the 
head  collapses  delivery  may  be  effected  either  by  version  or 
by  means  of  a  cranioclast. 


HYDROCEPHALUS. 


251 


Forceps  should  never  be  applied  to  a  hydrocephalic  head 
if  the  condition  is  at  all  marked,  as  it  is  impossil)le  to  secure 
a  ^ood  grasp  on  account  of  its  compressibility. 

When  the  breech  preseiiti<,  the  trunk  and  arms  may  be  ex- 
tracted and  an  attempt  made  to  perforate  the  cranial  vault  by 


Fig.  90. 


i 


Thinning  of  lower  segment  of  uterus  in  ohstruotion  from  hydrocephalus. 

(After  Bundl.) 


tlie  temporal  fontanelle.  If  this  cannot  be  reached,  then  the 
spinal  canal  should  be  opened  in  the  dorsal  region  by  means 
of  a  pair  of  scissors,  and  a  catheter  passed  through  it  into 
tlie  cranial  cavity  and  the  fluid  thus  evacuated  (Van  Huevel's 
method  :  Fig.  91). 


/  i 


252 


PATHOLOGY   OF  LABOR. 


Puncture  of  spinal  canal  in  a  case  of  hydrocephalus  obstructing  labor 

(After  Ilerrfenjt.) 

Encephalocele ;  Meningocele ;  Hydrencephalus. 

Tliose  conditions  when  present  do  not  often  seriously  ooiii- 
plicate  labor,  as  the  tumors  are  either  small  or  are  so  situ- 
ated that  tliey  fail  to  affect  materially  the  progress  of  tlir 
case.  If  obstruction  to  labor  occur,  the  trrowth  should  !»<' 
perforated,  when  its  contents  will  drain  away  and  make  dc- 
Hvery  possible. 

Tumors  of  the  Foetal  Trunk. 

Certain  tumors  arising  in  connection  with  the  fcetal  trunk 
may  by  their  bulk  or  situation  induce  dystocia. 


DYSTOCIA   DUE  TO  ABNORMALITIKS,  ETC.  253 

Varieties:  Spina  hifida  ;  tcratomata  siliiatod  on  tlie  spine, 
jaw,  or  orbit ;  liydrothorax  ;  asi'itos  ;  cystic  defeneration  of 
ilie  kidneys;  inali<;nant  conditions  of  tlu!  liver,  spleen,  or 
pancreas  ;  distention  of  the  urinary  Madder,  and  hernia  of 
viscera  through  clefts  in  the  abdominal  or  thoracic  walls,  may 
1)0  mentioned  under  this  heading. 

Treatment:  Should  delivery  be  delayed,  forceps  or  version 
may  l)e  resorted  to,  or  some  form  of  embryotomy.  Tumors 
with  Huid  contents  should  be  evacuated. 

Monstrosities. 

Anencephalus  or  hemicephalus  is  the  form  most  commonly 
met  with.  Delay  is  generally  caused  in  the  first  stage  by  the 
;ibsence  of  the  head  as  a  dilator.  Wiien  the  diagnosis  is 
made,  version,  if  possible,  should  be  performed. 

Double  monsters :  These  may  very  seriously  complicate 
labor;  but,  as  a  riile,  the  fcetuses  are  small  and  delivery 
occurs  naturally.  In  difticult  cases  craniotomy  or  some  other 
form  of  embryotomy  is  necessary  to  effect  delivery. 

DYSTOCIA   DUE    TO   ABNORMALITIES   OF    THE    F(ETAL 

APPENDAGES. 

Short  cord :  Cases  have  been  recorded  in  which  the  cord 
has  not  measured  more  than  two  inches  in  length.  Relative 
shortness  of  the  cord  may  occur  from  its  coiling  around  the 
neck  and  limbs  of  the  fcetus. 

The  condition  may  lead  to  premature  detachment  of  the 
})lacenta,  rupture  of  the  cord,  or  com])ression  of  its  vessels 
from  stretching,  which  results  in  death  of  the  feet  us. 

The  (UagnosiH  is  difficult.  Sometimes  the  patient  com- 
plains of  marked  pain  at  the  placental  site  during  each  con- 
tiaction.  Occasionally  a  j)ortion  of  the  uterine  wall  may  be 
felt  to  be  drawn  downward  and  inward  during  each  contrac- 
tion. Frequently  the  presenting  part  is  retracted  rapidly  as 
the  uterine  contraction  subsides. 

Treatment  consists  in  rapid  delivery  with  the  forceps  or  by 
version. 


254  PATHOLOGY  OF  LABOR. 

Prolapse  of  the  Cord. 

A  loop  of  the  umbilical  cord  may  prolapse  alongside  or  in 
front  of  the  presenting  part.  As  labor  progresses  the  cord 
is  exposed  to  pressure  between  the  presenting  part  and  tlic 
pelvic  wall,  which  results  in  interruption  of  the  fcetoplacental 
(^ir(;ulation,  and  possibly  in  the  death  of  the  ftjetus. 

Prolapse  of  the  cord  may  occur  either  before  or  after  rupt- 
ur(»  of  the  membranes. 

Frequency  :  This  accident  occurs  once  in  about  250  cases  of 
labor.  It  is  met  with  most  frequently  in  presentations  of 
the  pelvic  pole  of  the  f(etus. 

Etiology :  The  essential  cause  of  prolapse  of  the  cord  is 
failure  of  the  presenting  part  of  the  fcetus  to  fill,  completelv 
and  continuously,  the  lower  segment  of  the  uterus. 

The J'mtd/  cnudttlons  which  predispose  to  this  accident  are: 
malpositions  and  mal presentations ;  small  size  and  increased 
mobility  of  the  fcjtus ;  anomalies  of  other  f(etal  appendages, 
as  marginal  insertion  or  excessive  length  of  the  cord,  hydrain- 
nios,  placenta  pnevia  ;  and  sudden  escape  of  the  liquor  aniiiii 
with  the  patient  in  the  erect  position. 

The  predisposing  maternal  conditions  diVQ  :  pelvic  deformity  ; 
relaxed  abdominal  wall,  as  in  some  multipane ;  uterine  and 
other  tumors;  uterine  obliquity. 

Tl>e  accident  is  also  more  liable  to  occur  in  cases  of  multi- 
ple pregnancy. 

Diagnosis. 

Before  the  rupture  of  the  membranes  it  is  a  somewhat  dittl- 
cult  matter,  as  a  rule,  to  recognize  a  prolapse  of  the  cord  on 
account  of  its  non-resisting  nature  and  the  ease  with  which 
it  recediis  before  the  examining  finger. 

After  rupture  of  the  membranes  it  may  be  generally  recog- 
nized without  difficulty,  on  account  of  its  twists  and  the  pulsa- 
tions of  its  vessels. 

It  has  been  not  infrequently  mistaken  for  a  ])rola])sed  looj) 
of  intestine  ;  and  occasionally  a  portion  of  intestine  has  been 
mistaken  for  the  cord.  Care  in  examination  should  make 
such  an  error  in  diagnosis  impossible. 

The  position  the  cord  usually  occupies  is  at  one  or  other 


PROLAPSE  OF  THE  CORD.  255 

side  of  tlio  pelvis  somewhat  posteriorly  ;  rarely  it  may  lie 
cither  in  front  of  the  promontory  or  behind  the  sym})hysis 
|»iil»is. 

When  the  foetal  heart-sounds  grow  progressively  weaker 
:iiid  no  cause  is  apparent,  prolapse  of  the  cord  should  be 
^llspecte(l  and  a})propriate  treatment  inaugurated. 

Prognosis. 

This  complication  rarely  influences  the  prognosis  for  the 
mother,  save  in  so  far  as  the  operative  treatment  exposes  her 
to  risks  of  shock  and  sepsis. 

For  the  child  the  prognosis  is  somewhat  grave,  the  mortality 
ri-'ing  to  somewhat  over  50  per  cent.  The  cause  of  f<etal 
(lentil  is  (Kjclusion  of  the  fetoplacental  circuilation  from  press- 
ure on  the  cord.  This  pressure  results  in  asphyriation  of 
tiie  child.  Should  the  prolapsed  portion  of  the  cord  show  an 
alisencc  of  pulsation  for  ten  or  fifteen  minutes,  and  abdominal 
auscultation  fail  to  permit  the  detection  of  heart-sounds,  the 
ticath  of  the  f(j'tus  is  assured. 

Treatment. 

If  the  child  has  perished,  no  treatment  is  indicated,  and 
the  case  may  be  left  to  Nature. 

Before  rupture  of  the  membranes:  The  indications  for 
treatment  are  to  prevent  rupture  of  the  membranes  as  long  as 
possible,  and  to  favor  the  replacement  of  the  cord  by  appro- 
piiate  posturing  of  the  patient.  The  woman  should  be  made 
to  adopt  the  o:enupcct()ral  posture  (Fig.  92).  While  the 
]);iticnt  is  in  this  position  the  influence  of  gravity  causes  tlu; 
(•i>rd  to  settle  slowly  toward  the  fundus,  and  thus  the  j)ro- 
lapsod  loop  is  gradually  withdrawn.  Diiriiif/  the  infcrrdfx  be- 
tween the  pains  this  may  be  gently  pushed  back  with  the 
iiaiid,  care  being  taken  not  to  rupture  the  membranes.  When 
the  romJition  has  been  corrected,  the  ])atient  may  be  permitted 
to  recline  on  the  side  ()j)}><).site  to  that  occu])icd  by  the  cord. 
The  change  of  position  should  be  made  slowly  and  carefully, 
so  as  to  avoid  forcino;  the  cord  down  again.  Tlic  mend)ranes 
may  then  be  ruptured,  care  being  taken  to  force  the  head 
down  by  pressure  from  above  while  this  is  being  done. 


250 


PATIIOLOGY  OF  LABOR. 


r(  - 

111- 

\< 

till 
II' 


After  rupture  of  the  membranes:  Rcforc  attomptinjr  to 
j)lii('o  the  prolapsed  loop  of  cord  after  rupture  of  the  \m 
brano.s,  eare  should  he  taken  to  find  out  whether  the  ehihi 
alive.  If  [)ulsation  has  eeased  in  the  eord,  the  heart  niav  s 
he  heating  ;  if  this  is  tin?  case,  the  presenting  j)art  siiould 
piished  up,  and  the  eord  replaced  after  j)uisation  returns. 

The  woman  should  he  [)laced  in  the  Sims  position  on  ;l;c 
!-ide  opposite  to  the  prolapsed  cord.  The  hips  should  he  (  1.  - 
vated  hy  means  of  a  folded  pillow.  The  oj)erat()r  should  tin  n 
push  hack  the  presenting  part  so  as  to  release  tlie  cord.    TJiis 


Fio.  92. 


Postural  trentmcnt  of  prolapse  of  the  cord. 


may  then  he  loosely  twisted,  care  heing  taken  not  to  interfi  re 
with  its  pulsations,  and  the  twisted  mass  gently  pushed  ii|» 
beyond  the  ])resenting  part. 

If  it  he  found  im])ossihle  to  replace  the  cord  with  the  woiiinn 
in  the  Sims  position,  she  should  be  placed  on  her  knees  and 
chest  and  another  attempt  made,  if  necessary  giving  an  aii.i  s- 
thetic  so  as  to  relax  the  uterus  com])letely.  The  objection 
to  the  knee-chest  position  is  the  tendency  for  air  to  enter  the 
uterine  cavity  ;  if  this  accident  occurs,  the  subsequent  lahor 
should  not  be  inididy  ]>rolonged. 

Should  maiHial  efforts  fail,  a  suitable  instrument  for  replac- 


VROLAV^E   OF  TUK  LORD. 


257 


iiitr  the  cord  may  Ix'  improvised  wltli  a  No.  10  or  .No.  I'J^iim 
chistic  cjitlu'tcr  mimI  some  tajtc.  A  loop  of  tajx*  is  made  to 
encircle  the  eonl  loox'Iy,  and  its  free  ends  are  attaeiie<l  to  the 
tip  of  the  catheter.  The  catheter,  witli  its  styh^t  iiiserte<l,  is 
tlirii  j)iished  well  up  int(>  the  uterus,  carrying  the  cord  with  it 
(I'igs.  03,  94,  and  UO).    The  stylet  is  then  withdrawn  and  the 


Fig.  93. 


Fm.  94. 


Reposition  of  cord. 
(Witkowski.) 


Braun's  ronosition  of  cord. 
(Witkowski.) 


catheter  left  in  the  uterus  to  come  away  with  the  child.  Care 
should  he  taken  to  remove  the  bone  button  from  the  end  of 
the  catheter. 

If  all  attempts  at  reposition  of  the  cord  fail,  then  either 
vrrsion  or  forccpK,  with  rapid  delivery,  must  be  resorted  to 
ill  order  to  save  the  life  of  the  child.  Befon;  either  of  these 
operations  the  loop  of  the  cord  should  be  ])laeed  opposite  the 
saero-iliac  joint,  where  it  will  be  least  pressed  upon. 

17— Obst, 


2'iH 


I'ATIIOl.iKlY   OF   LMiOIt. 


^X\ 


Coiling  of  the  Cord  about  the  Foetal  Neck. 

Quite  frequently  (lie  fulul  cord  is  foiiixl  to  'oc  coiled  alxtnt 
tli(!  iicciv  ol'  tlu!  child.      It  iiiiiy  cncircK;  tlic  neck  several  tiim  -, 

and  thus  |)i'odi;ce  a  relative  shorteiiiiiLr 
1"  1(1.  l»").  ol'  the  ('(trd. 

'i'he  condition  is  dillicult  to  diagnose 
before  delivery  of  tlu;  head.  It  niiv 
l)e  suspected  if  the  head  descends  will 
witii  each  pain,  hnt  rapidly  recedes  in 
the  interval  hetween  the  contractioi!>. 

Results:  Occasionally  the  traction  is 
.so  severe  as  to  interfere  with  the  fold- 
placental  circnlation  ;  and  has  hci  n 
known  to  cause;  premature  detachini  in 
of  the  placenta. 

The  only  treatment  that  can  he  .-iil"^- 
^ested  is  the  a])plieati()n  of  the  for('(|ts 
and  the  rapid  delivery  of  tlie  he:iil  ; 
when  the  cord  may  he  cut  and  un- 
coiled from  the  net^k  before  the  biiili 
of  the  trunk  takes  place. 

Placenta  Prsevia. 

The  placenta  is  normally  implanted 
entirely  within  the  upper  uterine  m'^:^- 
ment. 

When  it  is  im])lanted,  in  wh(>le  or  in 
part,  upon  the  lower  uterine  .segment  tin 
condition  is  known  as  placenta  praevia. 

Varieties:  Three  varieties  are  de- 
scribed : 

(1)  Placenta  prievia  centralis:  The 
placenta  is  so  situated  that  its  centre 
corresponds  with  the  internal  os  (Fiir. 
96). 

(2)  Placenta  prjcvia  marginalis  :  'Die 
placenta  is  situated  so  that  but  a  ])ortion  of  its  margin  ov<r- 
laps  the  internal  os  (Fig.  97). 

(8)   Placenta  praevia  lateralis:  The  placenta  is  situated  "n 


Another  method  of  reposi- 
tion of  cord. 


PLACESTA    I'lLKVlA. 


2r)!) 


tlic  lateral  wall  of  tlu'  uterus,  extending;  well   «l«»wn    into  the 
li.wer   segment,   l)ut    not    reaching-  a>   far  as  the    internal    os 

(l'i^^^>H). 

In  the  central  and  niarj^inal  varieties  the  hemorrhage  may 
lic^dn  early  in  prejjjnaney  ;  it  is  repeated  frecjUently,  and  in 
lahor  is  niueh  more  serious  than  in  the  lateral  variety. 


Flu.  %. 


Fui.  i»7, 


riat'fiitti  pr.i'via  centralis.  I'liiccnla  praviu  iiiarKiiialis. 

Fig.  98. 


Placenta  pravia  lateralis.    (After  Dakin.) 

Frequency:  Placenta  pnevia  centralis  is  very  rare;  lateral 
:iii(l  marginal  placenta  prjevia  are  the  commctnest  varieties. 
Placenta  pnevia  occurs  about  once  in  1000  cases.  It  is  more 
i'n'(|uently  met  with  in  multipane  than  in  |)rimipar{e. 

Etiology:  A   satisfactory  explanation  of  the  occurrence  of 


i-f 


2G0  PATHOLOGY  OF  LABOR. 

])l5icenta  j)ncvia  lias  never  been  advanced.     Clironic  inHaminu- 
tory  <'liantj:es  in  the  mucous  nicinhrane  certainly  prcdisjKisc  i,, 
its  occurrence;.     Other   probable    causes    are:    subinvolutinn. 
atrophy  of  the  decidua,  new  growths,  and  inalforniations  ol 
the  uterus. 

Symptoms  and  Physical  Signs. 

'I'lie  symptoms  of  placenta  pra'via  do  not  usually  prcx m 
themselves  until  after  the  sixth  month  of  nre<2:nancv. 

The  first  indication  of  the  condition  is  a  sudden  gush  of 
blood  from  the  genitals,  usually  without  apparent  cause  and 
without  pain.  The  bleeding  then  recurs  at  intervals  as  pii  l-^- 
nancy  advances.  'V\\i\  amount  of  blood  lost  is  proportionaU' 
to  the  extent  of  the  placental  separation.  \\'hen  hemorrhage 
takes  ])lace  during  pregnancy  it  is  j)robably  due  to  a  i)ai!ial 
separation  of  the  placenta  in  the  lower  uterine  segment,  wluiv 
its  attaciiinent  is  im])erfeot.  This  separation  is  caused  by  ilic 
normal  uterine  cc/Utractions  which  constantly  occur  throuuh- 
oiit  pregnancy. 

The  first  hemorrhage  wlien  it  occiu's  during  la})or  may  be  so 
severe  as  to  threaten  the  patient's  life.  As  a  rule,  the  blecdir  i; 
is  most  profuse  in  the  intervals  l)etween  the  pains;  but  this 
cannot  be  said  to  be  diagnostic  of  the  condition. 

\\y  abdominal  examination  the  location  of  the  ])lac(>nta  mav 
be  re<'ognized,  uhen  the  implantation  is  on  the  anterior  uterine 
wall,  by  feeling  its  edge,  which  presents  as-  a  resisting  y\\\)i. 
Below  this  point  the  uterus  feels  soft  and  boggy,  and  the  fo'tal 
parts  can  oidv  be  felt  indistinctlv,  while  elsewhere  thev  mav 
be  readily  made  out.  Over  this  boggy  area  the  placental  hniif 
is  to  be  heard  with  great  distinctness.  If  the  larger  portion 
of  the  placenta  occupies  tlw  lower  uterine  segnunt,  mal|»ic— 
entations  of  the  fu'tus  may  occur,  a-;  the  presenting  part  is 
thus  prevented  entering  the  pelvic  brim. 

Wy  vaginal  examination  the  cervix  and  lower  uterine  scnf- 
ment  are  found  to  be  softer  than  usual.  If  the  insertion  of 
the  placenta  is  marginal,  one  side  of  the  cervix  and  lower  seiz;- 
mont  may  be  softer  and  more  bogiry  than  the  other.  Pul- 
sating vessels  may  be  felt  around  the  cervix. 

Tlie  external  os  is  usually  patulous,  and  through  it  the 
finger  may  be  pushed  till  the  internal  os  is  reached,  where  the 


I'LACJ'jyTA  PR^JVIA.  261 

matornal  siirfaoe  of  the  placenta  may  be  felt,  a  gritty  feel  (.lis- 
tiniriiishiiiir  it  from  a  blood-clot  or  the  membranes. 

Diagnosis. 

When  homorrhaj>:o  takes  place  in  the  later  months  of  preijj- 
iiancv  a  careful  examination  siiould  be  made  to  ascertain  its 
cause.  The  ruj)ture  of  a  varicosed  vein  in  the  vagina  and 
pi'cmature  detachment  of  the  normally  situated  placenta  may 
icail  to  severe  hemorrhage  in  the  later  months  of  pregnancy. 
A  carefid  and  s.stematic  examination  will  generally  permit  u 
tliagnosis  to  be  made. 

Treatment  of  Placenta  Praev^.a. 

The  control  of  hemorrhage  is  the  principal  indication  of 
treatment. 

In  the  rare  cases  in  which  the  condition  of  placenta  j)rievia 
is  recognized  before  the  fetus  is  viable  it  may  be  j)ossil)le  to 
carry  out  an  expectant  plan  of  treatment  imtil  the  seventh 
month  of  the  ])regnancy  is  reached.  The  patient  must  be 
kept  in  bed,  not  being  permitted  to  rise  for  any  purpose.  It 
may  be  well  to  administer  chloral  (gr.  xv)  or  li(|.  opii  sed. 
(nixv)  two  or  three  times  daily  to  t    utrol  the  nervous  system. 

When  the  seventh  month  has  been  reached  labor  shoidd  be 
induced,  as  after  this  j)eriod  the  woman  may  bleed  to  death 
he  fore  medical  aid  can  reach  her. 

Being  satisfied  that  the  condition  of  placenta  pnevia  is 
present,  it  is  the  duty  of  the  physician  at  once  to  empty  the 
uterus  if  the  child  is  viable. 

The  ])atient  should  be  an.Tstheti/ed  and  ))laced  in  the 
lithotomy  position,  with  her  hips  at  the  edge  of  the  bed.  A 
Kelly  pad  should  be  ])laced  inulcr  her.  The  vulva  and  vagina 
should  then  be  scrubbed  and  doucled  with  formalin  or  bi- 
<iiloride  solution.     The  operator  liaving  sterilized   his  hands  « 

and  arms,  shoidd  then    dilate    the    cervix    by  inserting   one     .j  .,  ,^/^jyi 
linger,  then  a  second,  and  then  the  thumb  of  the  right  hand. 
Search  should  then  be  made  for  the  edge  of  the  j)lacenta.      If 
the    placenta  is  lateral  or  marginal,   it    may  be  sutH(,'ient   to 
rupture  tlie  membranes,  tearing  them  freely,  and  to  sweep  the 


202  PATHOLOGY   '  F  LAliOR. 

finders  round  iiiidcr  tlio  margin  of  the  placenta  so  as  to  sepa- 
rate it  from  tile  uterus  for  a  short  distance.  The  tingers  ni;iv 
tlien  l)e  witlidrawn  if  tiie  head  of  tiie  fVrtus  is  presentinL.. 
Firm  pressure  on  tlie  funchis,  so  as  to  crowd  tiie  iiead  into  tin' 
j)elvis,  may  tiien  l)e  suflitMent  to  control  tiie  iiemorrliage ;  it 
so,  the  case  may  now  he  left  to  Nature.  If  tlie  os  lias  ))een  siii- 
ficiently  dilated,  tiie  forceps  may  he  ajiplied  and  the  licini 
diawn  down,  after  wiiicii  tiie  case  mav  Ije  left  to  Nature  1m 
deliver. 

If  tiie  placenta  is  central,  or  if  a  considerable  portion  of  tlic 
placenta  is  found  over  the  internal  os,  the  proper  treatment  is 
to  perform  internal  version.  A  foot  is  seized  and  drawn 
down  until  the  hemorriiage  is  ciiecked.  From  time  to  time 
tlie  protruding  leg  may  be  drawn  upon  to  hasten  dilatation  nf 
the  cervix.  Plenty  of  time  must  be  allowed  for  tiie  cervix  to 
dihite  completely,  otiierwise  tliere  will  be  difHculty  in  extract- 
ing the  after-coming  head. 

Xi  ther(>  iias  licen  a  great  loss  of  lilood  and  the  cervix  is 
found  to  be  rigid,  it  is  better  to  ])ack  the  cervix  and  vagina 
\\\\\\  sterile  iodoform  gauze,  whicii  may  be  left  in  ))lace  until 
the  patient  lias  had  time  to  rally  under  appropriate  treatiiK  nt 
(see  l\ist-partum  Hemorrliage).  The  gauze  tampon  not  only 
ciiecks  the  hemorrhage,  Imt  also  assists  in  softening  and  di- 
lating the  cervix  and  os. 

]\Iany  authors  recommend  the  cmjiloynient  of  hydrostatic 
dilators  instead  of  the  gauze  tampon.  Tiic  Ciiampetier  dc 
Ribes  i)ag  is  the  best  for  tiiis  ])urpose.  It  is  claimed  that  the 
bag  controls  the  hemorrliage  and  dilates  the  cervix  more  elV( « t- 
ually  than  does  tlie  vaginal  ])acking,  while  it  as  a  rule  causes 
less  discomfort  to  the  patient.  For  the  introduction  of  the  imu 
tiie  patient  is  placed  in  the  lithotomy  position,  the  anterior  lip 
of  the  cervix  is  seized  witii  a  tenaculum  and  drawn  will 
forward,  being  thou  held  by  an  assistant.  The  dilating  bag  i- 
folded  into  a  cylinder,  grasped  with  a  pair  of  forcojis,  and 
guided  carefully  into  the  cervix  and  tiirough  tiie  internal  os. 
Before  withdrawing  tiie  forceps  the  distention  of  tiie  hau 
sliould  be  commenced  in*  injecting  into  it  boiled  water  hy 
means  of  a  syringe  attached  to  the  tube  of  tiie  bag.  Tiien  as 
the  bag  distends  the  forceps  may  be  unlocked  and  carefnlly 
withdrawn.     As  a  precaution  against  rupture  of  the  bag,  the 


PREMATURE  SERA  RATIOS   OE   RLACESTA.  26^ 

iiperator  should  ascertain  heforcliaiid  li()\v  many  hiilUfiils  of 
natcr  are  rtMjuirod  to  dilate  it  completely. 

The  most  rigid  precautions  a^  ret;ards  asepsis  should  he 
observed  in  the  treatment  of  ])lacenta  pnevia,  as  the  risk  of 
infection  is  greater  than  in  ordinary  cases,  on  account  of  the 
low  position  of  the  placental  site. 

After  the  child  has  been  delivered  the  operator  should  intro- 
duce his  hand  into  the  uterus  to  remove  the  j)iacenta  and  any 
clots  that  may  he  fouiul  there.  'I'his  shoid<'  l)e  followed  hy  a 
prolonged  hot  intra-uterine  douche  of  stei'iK  salt  solution  or 
1  :  500  formalin.  A  full  dose  of  the  fluid  extra(;t  of  ergot 
should  he  administered  as  soon  as  the  uterus  is  em[)tied,  or 
else  a  hypodermic  of  ergotin. 

Prognosis :  Placenta  ])r{evia  constitutes  a  most  serious  com- 
plication of  pregnancy  or  labor  for  both  mother  or  child. 
I'lider  prompt  and  aseptic  treatment  the  maternal  mortality 
should  be  practically  nil.  As  premature  delivery  is  frecpient, 
the  infant  mortality-rate  is  high. 

Premature  Separation  of  a  Normally  Situated  Placenta : 
' "Accidental  Hemorrhage . 

The  hemorrhage  associated  with  premature  detachment  of 
a  normally  situated  placenta  is  termed  "accidental,"  to  dis- 
tinguish it  from  the  "unavoidable"  hemorrhage  of  placenta 
j)r;evia. 

Varieties :  Accidental  hemorrhage  may  be  apparent  or  con- 
rrtiled. 

Fn  apparent  accidental  hemorrhage  the  blood  dissects  its 
way  between  the  membranes  and  decidua,  and  escapes  through 
the  cervix. 

In  concealed  accidental  hemorrhage  the  blood  fails  to  find 
a  way  of  escape,  and  may  collect  Avithin  the  uterus  in  sulli- 
cient  ([uantity  to  cause  serious  symj)toms,  or  even  death  of  tlu; 
patient. 

In  this  form  anv  of  the  followin";  conditions  mav  obtain  and 
prevent  tJic  escape  of  blood : 

1.  The  placenta  may  be  detached  only  at  the  centre,  the 
margin   remaining  adherent ; 


264 


PATHOLOGY  OF  LABOR 


2.  The  upper  margin  may  be  detached,  so  that  blood  accu- 
mulates between  the  membranes  and  the  uterine  wall  ; 

»5.  A  portion  of  the  ed-rc 
t'i*^'.  99.    •  of  the    placenta  and  of  the 

adjacent  membranes  may  he 
detached ;  the  latter  m;i\ 
rupture  and  permit  the  bhx.il 
to  mingle  with  the  licpioi 
amnii  in  the  sac. 

4.  The  cervix  mav  be  oh- 
.structed  by  a  clot,  the  de- 
tached membranes,  or  the 
j)resenting  part  of  the  ftetiis 
(Fig.  <){)). 

Etiology :  The  predis])()s- 
ing  causes  may  be  given  a>, 
tubercular  and  syphilitic  <lc- 
uencration  of  the  decidiia, 
j)Iaccntal  degenerations,  nc- 
j)liritis,  ana'mia,  and  tin- 
acute  infectious  diseases.  In 
the  ])rcsence  of  these  but  ti 
trivial  exciting  cause  is  re- 
quired to  produce  separation 
of  the  placenta.  A  sudden 
jar,  a  blow  on  the  abdomen, 
or  violent  muscular  exertion 
may  be  all  that  is  required 
to  bring  about  such  a  senara- 

Frozcn  sootion  of  the  uterus  of  a       ,.  *^  ^ 

wniTinn  who  dit'il  of  aopidcntal  hcnior-      tlOU. 
rliaRc    at    the    >[aternite   de    Beaujon. 
(I'inard  and  Varnier.) 


Symptoms  and  Diagnosis  of  Accidental  Hemorrhage. 

The  symptoms  resemble  those  of  rupture  of  the  uterus, 
but  are  not  so  severe. 

In  the  appa'  mt  variety  the  fact  of  hemorrhage  is  obvious. 
It  usually  takes  place  early  in  labor  or  during  the  later 
months  of  ])regnancy.  Severe  localized  pain  at  the  placental 
site  is  not  infrequent.     The  uterus  may  bulge  at  this  point. 


PRKMATVRE  SKPAIiATIOX  OF  PLACKXTA.  2(55 

Placenta  pnevia  is  readily  distingiiished  by  a  careful  vaginal 
examination. 

Concealed  hemorrhage  is  generally  revealed  by  the  systemic 
ctVects.  Rapid  pulse,  pallor,  cold  extremities,  restlessness, 
sighing  respiration,  and  collai)se  may  be  j)resent.  Jf  labor 
has  begun,  the  uterine  contractions  cease  or  become  weak, 
though  the  patient  may  com])lain  of  inon.'  or  less  continual 
pain  at  the  placental  site.  ()n  abdominal  examination  the 
uterine  wall  may  be  found  bulging  at  the  seat  of  the  hemor- 
rhage and  the  ffctal  heart-sounds  are  feeble  and  irregular. 
llii|)ture  of  the  uterus  may  be  distinguished  from  concealed 
accidental  hemorrhage  bv  the  fact  that  the  former  occtu's  late 
in  labor,  usually  after  rupture  of  the  membranes,  and  that  the 
presenting  part  of  the  fcetus  recedes. 

Prognosis. 

In  apparent  hemorrhage  the  prognosis  is  good  for  the 
mother,  but  not  favorable  for  the  child.  If  labor  does  not 
come  on  at  once,  there  is  danger  of  infection  of  the  blood- 
tract  between  the  edge  of  the  placenta  and  the  os,  residting 
in  sej)sis. 

In  the  concealed  hemorrhage  the  percentage  of  mortality  for 
hoth  mother  and  child  is  high.  Death  results  from  hemor- 
rhage, shock,  extreme  ansemia,  or  sepsis.  The  f(etal  mortality 
is  due  to  interference  with  the  uteroplacental  circulation. 

Treatment. 

External  variety  :  If  the  external  hemorrhage  is  moderate 
ill  amount,  a  full  dose  of  o])ium  (li(j.  opii  sed.,  lllxxv)  and 
rest  in  bed  for  a  few  days  will  be  the  only  treatment  recpiired. 
The  patient's  temperature  shoidd  be  taken  twice  daily  for  a 
week  or  ten  days,  and  if  evidences  of  infection  of  the  blood- 
tract  occurs  the  uterus  should  be  emptied.  When  the  blood- 
loss  is  alarniins:  it  inav  be  necessarv  to  induce  labor.  The  os 
should  be  dilated  digitally  to  ])ei-mit  ru]>ture  of  the  mem- 
hranes.  A  Barnes  or  Champetier  de  Kibes  bag  may  then  be 
introduced  into  the  cervix  and  left  there  till  it  is  expelled, 
when  forceps  may  be  apj)lied,  should  the  Ibrces  of  Nature  fail 
in  promptly  effecting  delivery.    When  it  is  recjuired  to  empty 


2<;()  rwTiioLoay  of  lahoh. 

tlu!  utcni.s  iiiiiiuidiati'ly,  the  cervix  sliould  he  dilated  r:i|>i(||\  • 
if  necessary,  it  siioidd  l)e  incised  and  version  performed. 

Concealed  variety:  If  tlie  patient's  condition  is  sndi  us  tu 
forhid  active  obstetric  interference,  the  treatment  sliould  li' 
directed  to  combatinjj;  the  etlects  of  the  shock  and  iienioi- 
rhajre  (see  Treatment  of  I\)st-])artnm  Hemorrhage). 

The  fnn(his  should  he  compressed  hy  means  of  a  suu<:lv 
fittinjjj  l)inder  and  pad.  Tiie  loot  of  the  bed  sliould  he  el<  - 
vated. 

When  the  patient's  condition  })ermits,  tlu!  uterus  should  Im 
emi)tied  hy  means  of  manual  dilatation  of  the  cervix  and  vii- 
sion.     The  ))lacenta  in  these  cases  should   he  remove*)  inaiui- 
ally,  and  a  hot  intra-uterine  injection  should  be  given  afi*  r 
the  uterus  lias   been  emptied. 

Tiie  after-treatment  should  be  directed  to  controlliuix  the 
effects  of  severe  hemorrhage,  and  to  securing  good  uterini' 
contraction. 

Retained  Placenta. 

This  condition  is  of  frequent  occurrence.  The  j)lacenta  is 
usually  completely  detached,  and  lies  in  tiie  dilate<l  lower 
uterine  segment  or  in  the  upper  ])art  (>f  the  vagina. 

Causes:  Feeble  uterine  contractions,  or,  more  frefpientU . 
improper  methods  of  placental  expression,  generally  give  ri-c 
to  the  condition.  A  full  bladder  or  rectum  may  lead  to  reten- 
tion of  the  placenta. 

Treatment:  The  ])roper  apj>lication  of  Crede's  method  ..t' 
expression  is  usually  all  that  is  re(iuired  in  the  way  of  tnni- 
ment.  The  uterus  may  be  steadied  and  held  in  ])osition  liy 
laying  one  hand  across  the  sujirapuhic;  region  of  the  abdoimii, 
while  the  other  firndy  squeezes  the  fundus  and  at  the  same 
time  exerts  pressure  in  the  axis  of  the  pelvic  inlet  (lurin;/  <t 
uterine  con! I'dction.  This  method  will  rarely  fail  to  secur(!  ex- 
pulsion of  the  ])lacenta.  A^ery  occasionally  it  may  he  neces- 
sary to  introdut!e  a  cou]>le  of  fingers  into  the  vagina,  so  as  ht 
rtnich  the  lower  edge  of  the  placenta  and  hook  it  forward. 

Adherent  Placenta. 

In  this  condition,  which  is  rare,  the  placenta  is  not  onlv 
retained,  but  is  also  adherent  to  the  uterine  wall.     The  adlu  - 


AhllEREST  PL  A  ( 'KXTA . 


'2i\: 


-ion    is  riuvly  complete  ;   a  part  of  tlie  placenta  is    usually 
detached.     The  turn  siiuises  bleed   [)r(»f"usely,  as  the   uterus 


Fig.  100. 


ii 


Artificial  removal  of  adherent  placenta.    (Modified  from  Ribemcnt-Dessaigncs  and 

Lei>af,'e) 


"luuiot  contract    properly  on  account  of  the  portion  of  the 
jihicenta  which  remains  adherent. 

Causes  :    The  most  frecpient  cause  is  a   placentitis  (or  de- 
cidual inHammation)  of  specific  ori<^in.     Chronic  endomc.'triti.s 


2<J8  PATHOLOGY  OF  LABOR. 

and  placontal  do^oiu'raticms,  due  to  dironir  ncpliritis  in  the 
niothor,  may  give  riso  to  adluiPcnt  placenta. 

Treatment:  If  Crodr's  nictliod  </f' oxprossion  fails  and  the 
licinorriiagc  is  profuse,  the  eavity  of  the  uterus  must  he  enter((l 
and  th(!  placenta  gently  separated  and  removed. 

To  perform  this  operation  on(!  hand  grasps  the  fund'i- 
seourely,  while  the  other  is  inserted  into  the  vagina  and  lui- 
lows  up  the  cord  as  a  guide  till  the  placenta  is  reached.  A 
detached  (jdge  is  then  felt  for,  the  finger  tips  inserted  betwci  n 
the  placenta  and  the  uterine  wall,  and  hy  gentle  lateral  move- 
ments of  the  hand  the  sej)aration  is  completed  and  iL 
placenta  gently  grasj)ed.  The  outer  hand  then  makes  fric- 
tion over  the  fundus  until  a  contraction  has  hccn  stimulated. 
when  the  internal  hand  and  placenta  are  slowly  withdiawn 
(Fig.  100). 

The  internal  hand  and  the  j)lacenta  should  never  be  witli- 
drawn  until  uterine  contraction  has  occurred,  on  account  nt 
the  danger  of  producing  inversion  of  the  uterus.  The  luiml 
should  then  he  re-introduced  and  the  whole  titerine  caviiv 
explored  to  make  sure  tiiat  no  fragments  of  placental  ti>-ii( 
have  been  retained.  A  hot  intra-iiterine  douche  should  then 
be  given.  It  is  advisable  to  administer  a  full  dose  of  ergot  as 
soon  as  the  uterus  has  been  emj)tied. 

MATERNAL  DYSTOCIA. 

The  subject  of  maternal  dystocia  may  be  divided  into  three 
headings : 

1.  Anomalies  in  the  forces  of  labor  ; 

2.  Anomalies  in  the  pelvis; 

3.  Anomalies  in  the  maternal  soft  structures. 

1.  ANOMALIES  IN  THE  FORCES  OF  LABOR. 

Precipitate  Labor. 

Excessive  power  in  the  expulsive  forces  of  labor  may  result 
in  the  very  speedy  comjdetion  of  the  act. 

Etiology  :  The  condition  is  usually  due  to  undue  e.vcltahUifii 
of  the  .sympathetic  nervous   system,  rather   than  to   excessive 


FliECIPITATJ':  LAHOR.  2G!) 

imiscii];ir  dovelopmont.  It  may  tlu'rofort'  be  met  with  in 
\i)im<j:  j)riini|)arje,  as  well  as  in  woint'ii  of  more  ailvanccd  ajj^c 
anil  of  (greater  iniisciilar  (leV('lo|)iiU'iit.  'Vhv  rule  is  that  tlu; 
lirccipitancv  occurs  in  the  ti(V(Jii({  Minjc  of  labor,  the  lirst  sta<re 
iiciiii;  ijiiite  normal. 

Cnndifions  causiiuj  rdaxatlon  of  the  pelvic  floor,  as  dchili- 
tatintj^  diseases,  previous  laceration,  etc.,  favor  the  occnrriiice 
I  if  ])recipitate  labor. 

I*()ii'crfii/  ciaofionx,  such  as  fear  or  anxietv,  mav  act  bv 
increasing  tlu;  force  of  the  uterine  contractions. 

Sudden  and  poircr/ul  aicrine  eantrddion  irifh  the  patient  in 
the  erect  poHtarc  may  result  in  the  rapid  expulsion  of  the 
fetus,  which  may  fall  to  the  floor  and  receive  serious  injury. 
Thus  it  not  infre(|uently  happens  that  women  are  suddenly 
delivered  while  sittinji^  in  a  privy  or  water-closet,  and  the 
child  may  fall  into  the  cesspit  or  bowl  of  the  closet  and 
])('rish  before  aid  is  secured. 

Prognosis  :  Lacerations  of  the  vaj^ina  and  perineum,  heinor- 
rliajije  from  partial  or  comj)lctc  separation  of  the  placenta, 
inversion  of  the  uterus,  and  occasionally  retention  of  the 
placenta,  associated  with  hour-glass  contraction  of  the  uterus, 
may  be  mentioned  as  secpiehe  of  precipitate  labor. 

The  sudden  evacuation  of  the  uterine  contents  may  lead  to 
severe  or  even  fatal  syncope  on  the  part  of  the  mother.  The 
fictal  mortality  is  somewhat  greater  than  normal. 

Treatment :  When  the  uterine  action  is  powei'ful  and  the 
fictus  descends  ra]>idly,  it  may  be  lie/d  hack  by  inserting  the 
fingers  in  the  vagina  and  resisting  the  advance  of  the  pre- 
senting part,  while  at  the  same  time  chloroform  is  administere<l 
to  the  mother.  The  patient  should  be  instruct<'<l  to  keep  the 
mouth  oj)en,  and  to  pant  or  cry  out  during  each  pain. 

If  a  previous  labor  has  been  precipitate,  the  woman  should 
he  ke})t  constantly  in  bed  after  the  onset  of  labor.  If  the 
pains  tend  to  become  too  powerful,  chloral  should  be  freely 
administered.  Fifteen  or  twentv  <j:rains  mav  be  ijiven  at  a 
dose,  and  repeated  at  intervals  of  twenty  minutes  until  a 
<lrachm  has  been  given  or  the  action  of  the  drug  has  been 
obtained.  It  is  advisable  to  administer  chloroform  while 
waiting  for  the  chloral  to  be  absorbed  into  the  system. 

The  management  of  the  third  utatje  of  labor  demands  special 


270  I'ATllOLOUY  OF  LAliOR. 

care,  for  in  those  oases  there  is  often  a  nomplete  absence  <»(' 
contraction  after  delivery  of  thecliihl  ;  hence  the  uterus  Ix'conu., 
extremely  rehixed  in  the  intervals  hetwcen  the  jniins.  'lii.. 
finxhis  should  he  kept  well  inider  control,  lirni  friction  nui'l.' 
between  eaeli  pain  to  stimulate  contraction,  and  plenty  of  linu. 
should  be  j^iven  before  attempting  to  expel  the  placenta. 

II',  after  the  expulsion  of  the  placenta  the  uterus  does  n  ,( 
remain  contracted,  a  hot  (120°  F.)  intra-nterine  douche  sh(iiii(| 
be  ^iveii,  followed  by  a  hypodermic  injection  of  ergot  (asepiid 
TTl  XX.  The  fundus  should  be  controlled  until  the  uteni> 
remains  firmly  contracted. 

Delayed  Labor;  Uterine  Inertia. 

When  the  expulsive  action  of  the  uterus  is  unable  to  over- 
come the  normal  resistance  of  tlie  maternal  j)assages,  labor  is 
delayed  and  the  pains  are  said  to  be  "  weak." 

Causes  :  The  commonest  causes  of  uterine  inertia  are  pre- 
mature rupture  of  the  membranes,  rigid  os,  a  distended  bladder 
or  re<'tum,and  general  debility  of  the  patient.  Oblicpiity  of  the 
uterus;  overdistention,as  in  multiple  pregnancy  or  hydramiiids; 
degeneration  of  the  uterine  muscle-fibres  from  inflammation 
or  too  fre(pient  childbearing  ;  malpresentation  ;  uterine  tuniois 
or  tumors  of  neighboring  structures  ;  and  low  attachments  of 
the  placenta,  may  all  be  mentioned  as  causes  of  uterine  inertia. 

Diagnosis:  Before  making  a  diagnosis  of  uterine  inertia 
care  should  be  taken  to  ascertain  if  the  bladder  and  rectiiin 
have  been  emptied.  By  external  examination  the  contraction 
of  the  uterus  may  be  felt  to  be  weak,  for  the  organ  will  not 
assume  the  intense  hardness  associated  with  good  uterine 
action.  By  vaginal  examination  in  the  first  stage  the  bag  ot' 
waters  does  not  become  tense  during  a  pain,  or  if  the  mem- 
branes have  ruptured  the  presenting  part  does  not  descend. 

Examination  should  then  be  made  to  ascertain  that  the 
labor  is  not  delayed  by  some  obstruction. 

The  prognosis  depends  on  the  stage  of  labor  and  the  canso 
of  the  inertia.  In  the  first  stage  there  is  little  danger  to 
either  mother  or  child  unless  the  membranes  have  been  lonir 
rnj)tured.  In  the  second  stage  of  labor  there  is  danger  to 
both  mother  and  child  from  prolongation  of  the  labor. 


DELAYED   I.MlOli;    VTERISE  ISEliTlA.  271 

No  hard-and-fast  rule  as  to  liow  loiii;  delay  nilu^lit  l)o  with- 
<'iit  danger  can  l)0  lai<l  down.  When  the  licad  is  low  in  the 
pelvis  prolontxc*!  delay  may  cause  serious  injury  to  the  mater- 
nal j)arts  from  j)i'('ssure  of  the  head.  'J'he  condition  of  the 
mother  and  child  should  he  carefully  watched.  I)an»;er  to 
the  child  is  manifested  hy  a  slowing  of  the  fu'tal  heart's 
.ii'tion,  while  danger  to  the  inother  is  indicated  hy  local 
(idema  and  a  risinui;  j)ulso  and  temperaturi'.  It  may  he  said 
that  a  delay  of  over  six  hours  in  the  second  stage  warrants 
the  artificial  termination  of  the  lahoi. 

Treatment:  This  depends  on  the  stage  of  lahor  and  the 
cause  of  the  inertia.  'JMie  first  dutv  is  to  ascertain  the  cause 
(if  the  delay,  and,  if  possihle,  remove  it.  "^riie  hiadder 
and  rectum  should  he  emptied.  The  prolongation  of  the 
first  stage  of  lahor  may  have  exhausted  the  patient,  and  when 
this  is  the  case  no  effort  should  he  made  to  stinudate  uterine 
(untraetions  until  the  ])atient  has  heen  restored  hy  a  goo<l 
rest,  and,  if  possihle,  sleej).  This  may  he  accomplished  hy 
giving  her  a  hyjiodermic  injection  of  morj)hine  (|  gr.),  and 
repeating  it  in  half  an  hour  if  necessary.  At  the  same  time 
she  may  he  given  some  hot  hroth  or  milk,  or  some  sherry  and 
a  l)iscuit,  to  maintain  her  strength. 

Chloral  is  to  he  preferred  to  morphine,  as  it  seldom  arrests 
the  progress  of  lahor.  Two  drachms  of  the  syriij)  of  chloral 
may  he  given  in  a  cupful  of  warm  milk,  and  reju^ated  in 
half  an  hour  if  required.  On  waking,  the  patient  may  he 
trivcn  some  hot  hroth  or  eixtr-noir.  If  the  contractions  do  not 
then  set  in  with  increased  ])ower,  efforts  may  he  made  to 
stinudate  the  uterus  to  action. 

Si)-i/cli»im'  (gr.  -^f^),  administered  hypodermically,  is  proha- 
hly  the  most  valuahle  uterine  stimulant.  (Quinine  in  large 
(loses  (gr.  xv),  re])eated  in  half  an  hoiu',  acts  well  in  some 
cases;  hut  the  author  has  failed  to  find  it  completely  satis- 
factory. 

Krgot  is  only  mentioned  to  he  condemned,  for  it  tends  to 
induce  tetanic  uterine  action,  and  thus  interferes  with  the 
placental  circulation.  If  ftfiniild  iicrcr  he  us<'<l  intfH  flir  iifcrnti 
has  been  cmpt'tal.  Hot  vaginal  douches  (120°  F.),  given  at 
intervals  of  half  an  hour,  often  prove  of  great  value. 

Alcohol  has  proved  a  very  satisfactory  uterine  stimulant   in 


272 


PATlIOI.OdY  OF  LA  noli. 


the  tiiitlior's  exporit'iioc  ;  it  is  hcst  i^ivcii  in  tlic  form  of  slicnv, 
as  rccorumctKlcd  hy  Hirst,  and  should  !)('  slowly  sipjH'd,  lim 
patiiMJt  l)i'ini;  infornicd  that  it  will  surely  l)rin^  hack  llic 
pains  and   hasten  the  delivery. 

In  very  obstinate  vii>nis  n  .sfcri/izcd  hoiif/ir  may  he  inserii ,] 
into  the  nti-rus,  and  the  vajz^ina  paelced  lightly  with  iodot'iinn 
i;auzo,  as  for  the  induction  of  premature  lahor.  'I'he  iniio- 
duction  into  tlu;  cervix  of  a  Champetier  de  Ivihes  l»a<r  or  ola 
i»arnes  hai;'  is  a  V(M"y  useful  hut  troublesome  method  of  ti'ciii- 
ment.  These  not  only  stimulate  the  uterus  to  action,  bin 
dilate  the  cervix,  and  thus  assist  in  overcoming  the  resi>taiii c 
olfered  by  the  os. 

'V\w  /)(((/  of  iralers  should  not  bo  ru])tured  until  the  o-;  is 
dilated,  unless  it  is  evident  that  tlu.'re  is  an  ex(X'ss  of  licpior 
anmii  j>resent,  and  that  this  is  the  probable  cause  of  inelliciciit 
uterine  action. 

When  inertia  is  j)resent  in  the  second  .sfaf/c  of  labor  the 
patient  may  be  allowed  to  walk  about,  in  the  hope  that  the 
descent  of  the  head  under  the  influence  of  ^I'avity  will  set  up 
uteriiu!  action  by  rcHex  stimulation  of  the  |)elvic  floor. 

Pressure  on  the  fundus  with  the  patient  in  the  dorsal  jxisi- 
tion  may  i)rov(!  of  value  when  employed  durinji^  uterine  cdii- 
tra(!tions.  When  other  measures  fail  resource  must  be  had 
to  the   forcej)S  to  terminate   labor. 


2.  ANO.NrAIJKS   OF  THE  TELVIS. 

The  ^reat  majority  of  anomalies  of  the  pelvis  arc  of  the 
nature  of  contraction.  Contractions  in  the  diameters  of  tlic 
])elvic  brim  give  rise  to  the  most  serious  conseciuences  both 
to  mother  and  to  child,  in  proj)ortion  to  the  degree  of  ob- 
struction olfered  to  the  passage  of  the  f<etus. 

Frequency:  Until  recently  it  was  commonly  believed  that 
abnormal  pelves  wore  much  more  rarely  met  with  in  America 
than  in  Europe;  but  the  more  general  ])ractice  of  pelvimetry 
which  has  prevailed  in  obstetric  clinics  during  the  past  decade 
has  revealed  the  fact  that  in  America  deformity  of  the  pelvis 
is  met  with  in  about  the  same  proportion  of  women  as  in 
Europe. 

The  records  of  European  clinics  show  a  wide  variation  in 


AyOMALIl.'S  OF  Till':  PELVIS. 


21'.\ 


the  pcrcont;i<xos  r(>port»Ml,  llic  ditltToncc  oxtcudin^'  from  1.2 
|iir  <'(Mit.  ill  Iviissiii,  to  *J  l..">  |)('r  ('ciil.  in  S;i.\ouy.  \'oii 
\\  inckcl  ('oMsi<l<'i's  that  iVoiii  10  to  lo  per  cent,  ot"  (icrman 
witiucn  have  dct'onucd  [M'Ivcs  ;  luit  that  in  only  5  percent,  is 
tlio  ohstrnction  scrions  enonnli  U^  l)c  noti(wl. 

Ainont]^  Anjeri<'an  oltservers,'  Flint,  in  New  York,  fonnd 
I  12  per  cent,  of  pelvic  contraction;  iveynolds,  in  P>oston, 
1.1.'}  per  cent.;  ( 'rosseii,  in  St.  lioiiis,  7  percent.;  Dolihin, 
in  Haltiinore,  11.1.")  per  cent.;  and  W'illiains,  in  ilailiniorc, 
1;>.1  per  cent.  Davis,  fioni  tiic  records  of  1221  patients, 
((inclndes  that  2')  per  cent,  of  the  women  in  tlie  Ignited 
Slates  have  pelves  smaller  than  the  avera;i,(',  while  7  per  cent. 
have  pelves  Iar<^er  than  the  averaj^e. 

Hirst  states  that  detoiMned  pelves  are  hy  no  means  rare 
anionic:  native-horn   women   in  the  Eastern  States. 

Classification:  \"arions  classifications  ol'  pelvic^  anomalies 
have  heen  employed  in  dilTerent  countries,  hut  the  following-, 
taken  from  Jewett's  Pntcfior  of  ()/>s(c(ri<-s,  will  he  fonnd  snf- 
(iiiciitly  comprehensive  to  meet  all  re(|iiircments  : 

I.   Pelves  normally  proi)ortioiied  Init  ahnormal  in  size: 

1.  Fniformly  enlar<jjed  (  jnstomajor). 

2.  Uniformly  contracted  ( jnstominor). 

I  r.   Pelves   with   anomalies  of  size,  shape,  inclination,  or 
combinations  of  these  : 

1.  Those  with  minor  develojnnental  pecnliarities  : 

{(i)  ]\rasciiline ; 

(b)  Shallow; 

(c)  Deep ; 

((I)  Fiinnel-shapcd. 

2.  Anteroposteriorly  contracted  : 

(d)  Flat  non-rachitic  ;  j 
(h)  Flat  rachitic. 

3.  Obliquely  contracted  : 

(a)  By  imperfect  development  of  one  sacral  ala 

(Naeirelc  j)elvis)  ; 
(h)  By  imperfect  or  abolished  nse  of  one  limb  ; 
{(')   Uy  sj)inal  curvature. 

'  Davis,  K.  v.,  Aineiican  Journal  of  Obstetrics,  Jan.,  1900. 

JS-Ob.<t. 


274  VATIIOLOGY  OF  LABOR. 

4.  Transvcrsiily  contracted  : 

{(i)  By  imperfect  devclopnient  of  both  sacral  ako 

( Robert  pelvis) ; 
{/})   I>y  kyphosis  of  the  spine. 

5.  Compressed  pelvis  : 

(d)  JVfalacosteon  ; 

(b)  PseuiloiMalacosteon  rachitic. 

6.  Sj)ondylolisthetic. 

7.  Pelves  distorted   by  injnry,  tumors,  anchylosis  of 

joints. 

8.  Deformity  due  to  spinal  curvature  : 

{(i)  Kyphotic  ; 
(/;)  Scoliotic ; 
(<')  Kyphoscoliotic  ; 
((/)  Lordosis. 

Diagnosis :  Theoretlealh/  it  is  the  duty  of  the  physician  to 
take  careful  measurement  of  tlie  pelvis  of  every  woman  li(>  is 
calhsd  ui)on  to  attend  in  labor;  practically,  this  is  rarely  doDc 
until  delay  in  the  progress  of  labor  calls  attention  to  the  ilict 
that  possibly  some  obstruction  exists  in  the  pelvis. 

Deformity  of  the  pelvis  is  most  frcqnerifli/  met  with  in  those 
women  who  in  childhood  have  suffered  from  malmitiilidu, 
rickets,  or  tuberculosis  of  the  vertebne  or  joints  of  the  lower 
limbi-",  or  who  early  in  life  have  suffered  from  accident  to  a 
limb  which  has  resulted  in  shortening,  dislocation,  etc. 

Maldufrition  and  lutnl  vorl:  early  in  life  not  infre(|iictitly 
result  in  flattening  of  the  pelvic  brim.  Rickrt,^  may  lead  to 
various  serious  pelvic  deformities.  A  Jiixfofi/  of  late  dciiti- 
tii)n,  ])rolonged  indigestion,  of  not  walking  after  the  second 
vear,  v^ould  suti^irest  this  disease.  An  examination  of  sncli  a 
patient  might  reveal  the  square  head,  ])igeon-breast,  head- 
ing of  the  ribs,  or  bending  or  twisting  of  the  long  hones 
common  to  this  disease  Usually  these  patients  are  of  short 
stature. 

/)/,s'cr/.sr.s'  or  acriih'iifH  resulting  in  (h'formity  of  the  s|)Iiie  or 
lower  limbs  when  they  have  occurred  c<ir/i/  in  life  roiih  in 
'.bnormal  develo;  men^.  of  the  pelvis. 

F<ufu>\'  of  the  head  in  descend  info  the  pdrifi  at  or  before  tlie 
onset  of  labor,  associated  with  undue  proni'nence  of  the  alxlo- 


rh'LVIMKTRY. 


27  rj 


i;ien,  sliould  always  .siijj^gorit  oUstniftion  at  tlio  pelvic  brim 
wlu'ii  these  conditions  are  found  present  in  a  pi'imij)ara  with  a 
vi'Vtex  presentation. 

Pelvimetry. 

Deformities  of  the  pelvis  may  be  detected  by  rrfrrnaf  and 
infernal  pd/jHitioii  ;  and  by  inraimreinnds,  both  external  and 
internal,  of  those  diameters  of  the  pelvis  which  are  accessible. 

l'\)r  inkiiHj  jM'frir  nu'af-'Ui'einciif.s  the  examiner's  Hn<2;ers,  a 
ta|H'-measnre,  and  a  jiair  of  modified  calij)crs,  known  as  a  i)el- 
vimeter,  are  usually  employed.  The  jK'lvimeter  devised  by 
r»;iii<lelocque  in  177")  {V\g.  101)  is  probably  the  best,  though 
many  others  have  since  been  invented. 


Fig.  101. 


Baudelocque's  pelvimeter. 

Methods  of  Taking  Pelvic  Measurements. 

External  measurements  :  The  clothinji  of  the  patient  having 
hccii  rollc  '  well  out  of  the  way  and  the  lower  part  of  the  body 
covered  with  a  sheet,  she  lies  on  her  back  close  to  the  edge  of 


27()  rATlIOLOGY  OF  LABOR. 

tlic  1)('(1,  while  the  physician  stands  beside  lier  looking  tow  at.  i 
her  head.  He  then  takes  the  pelvimeter  and  holds  a  rod  n, 
eaeh  hand,  the  ti})  of  an  index-Hnger  being  on  each  knob,  ainl 
the  reading  snrf'aee  of  the  seah.'  held  so  as  to  be  easily  read. 

TIk;  knobs  of  the  pelvimeter  are  then  placed  on  thodidcn  r 
suinrior  xj)in<\s  of  f/ic  U'ki  or  on  the  t(.'nse  fascia  lata  just  beL  \v 
then),  as  suggested  by  Winckc^l.  In  the  normal  pelvis  tlil> 
measurement  should  be  about  lOj  inches  (2Bimi.)  ;  the  knni,s 
of  the  })elvimeter  are  then  moved  along  the  cvtcrnal  ahjix  nf 
the  i/iao  crests  until  the  greatest  distance  I.:  found,  the  measure- 
ment of  which  should  be  about  11  inches  (28  cm.),  'flic 
length  of  these  measurements,  as  well  as  any  im])()rtant  dilHr- 
ence  between  them,  enables  us  to  draw  our  conclusions  as  i<i 
the  development  of  the  innondnate  bones,  and  the  width  nj' 
the  trdmcerse  diameter  at  the  inlet. 

The  ])atient  is  then  made  to  turn  (m  her  side,  with  the 
thighs  slightly  Hexed.  The  knob  of  one  rod  is  then  placed  in 
the  depression  just  below  tJie  S2)iiie  of  the  last  lumbar  rertd  .n 
and  tirmly  h(;ld  in  this  position,  while  the  other  knob  !s  placi  (I 
on  the  sym[)hysis  ])ul)is  at  a  point  about  one-eighth  of  an  inch 
below  its  uj)per  border,  and  j)ressed  firmly  into  })osition.  The 
measurement  thus  obtained  should  bo  about  7i  inches  (1!) 
cm.),  and  is  known  as  the  external  conjugate,  or  the  diamf- 
tcr  of  Baudeloe(]iie.  To  obtain  an  idea  of  the  true  Cdii ju- 
gate •H  inches  (9  cm.)  should  be  <ieducted  from  the  nu  a>- 
urement  of  the  external  conjugate,  to  allow  for  the  thickness 
of  bone  and  soft  tissues;  this  would  give  the  normal  true 
conjugate,  4  inches  (10  cm.). 

The  ohli/jue  diameters  of  the  brimmay  be  measured  by  ])la(iiiLr 
one  knob  of  the  })elvimeter  in  the  depression  marking  ihc 
posterior  suj)erior  spine  of  cue  side,  and  the  other  knob  on 
the  anterior  su])erior  spine  of  the  opposite  side.  In  sym- 
metrical pelves  these  measurements  are  usually  equal,  and 
should  be  about  0  inches  (22.5  cm.). 

The  circumference  of  the  pelvis  may  be  measurc<'l  by  jtlacii'^' 
a  tajie-line  around  the  body,  so  that  it  will  ])ass  jus<"  over  the 
symphysis,  under  the  iliac  crests,  and  over  the  middle  of  iIh' 
sacrum  behind.  In  a  woman  of  average  development  and 
with  a  normal  })elvis  this  measurement  should  be  about  'loi 
inches  (DO  cm.). 


PELVIMETRY.  277 

The  otlicr  oxtoriial  nicasurcnu'iits  of  iinportaiicc  arc  tliosc 
tt'  tlic  (H((/<1  oj'  the  jH'lvis.  Tlic  (rdii^svcrHC  didincfcr  ot'  tlic  otit- 
!i't  is  uicasiired  by  placing  tlio  kn()l)s  of  the  pelvimeter  on  the 
inner  sides  of  the  ischial  tiilxtrosities.  The  (tiifcroposfcrior 
1 1  idiacter  \m\y  be  measured  l»y  jilacing  one  kiioh  of  the  pelvim- 
rtcr  on  tile  under  border  of  the  symj)hysis  pubis  and  the 
other  knob  on  the  skin  over  the  lower  border  of  the  tip  of  the 
acrum.  i^'rom  this  l.;}em.  nuist  be  deducted  to  allow  for 
iliicknessof  the  bone,  etc.  This  measurement  can  be  better 
(il)tain(!d  by  placing  the  tij)  of  the  middle  linger  of  the  left 
hand,  inserted  into  the  vagina,  against  the  end  of  the  sacrum 
:iiid  pressing  the  edge  of  the  hand  against  the  lower  bolder 
of  the  symphysis,  the  point  of  contact  being  marked  by  the 
iiidcx-Hnger  of  the  right  hand  and  the  distance  measured 
niter  the  left  han<l   has  been   withdrawn. 

Internal  measurements:  A  good  general  idea  of  the  ca})acity 
ol'  the  ])elvic  canal  may  be  obtained  from  a  careful  vaginal 
examination.  Thv  ])oints  of  importance  in  this  examination 
are  the  thickness,  height,  and  inclination  oi"  the  pubis;  the 
condition  of  the  lateral  walls  as  regards  ])roJcctions,  etc.;  the 
condition  of  the  sacrococcygeal  joint  ;  the  curve  of  the  sacrum  ; 
and  the  condition  of  the  })romontory,  if  this  can  be  reached. 

The  (lidf/onaf  covjuf/ah- — /.  f.,  the  measurement  from  the 
pi'omontory  to  the  sub])ubic  ligament — can  usually  be  ob- 
inined  without  much  ditficulty  j)rovidi'(l  the  examination  is 
made  carefully  and   methodically. 

The  ))atient  is  put  in  the  lithotomy  position  with  the  but- 
tocks projecting  over  the  edge  ol'  the  bed  or  table.  The 
examiner  then  introduces  t!ie  first  two  fingcM's  of  the  left  hand 
into  the  vagina  and  extends  them  inward  and  upward  until 
llic  tip  of  the  second  finger  rests  upon  the  promontory  of  the 
sKTum  (Fig.  102).  Care  must  be  taken  not  to  mistake  the 
l;ist  lumi)ar  vertebra  for  the  first  sacral,  or  ri<r  rosd.  The 
radial  side  of  the  hand  is  then  raised  until  the  impress  of 
tile  subpubic  ligament  is  felt  u|)on  it.  With  a  finger-nail  of 
tlif  other  hand  the  point  of  contact  is  marked,  and  both  hands 
tlirii  withdrawn.  \\'ith  a  pelvimeter  the  distance  between  the 
mark  and  the  tip  of  the  second  finger  is  then  measiircd.  This 
i>  the  length  of  the  diagonal  conjugate.  From  this  mcasiire- 
iiu'iit  I  inch  (1.75  cm.)  should  be  deducted  to  obtain  the  true 


278 


PATHOLOGY  OF  LABOR. 


coiijiij^ato  (liamotor.     This  average  (liircronoo  bctwoou  t\u>< 
two  cliamoters  (lepciids  upon  tlie  licight  of  tlio  syinpliysis  ( 1  ', 
inches,  4  cm.),  a  normal  angle  between  tlie  axis  of  the  ])u1ms 
and  the  true  conjugate  (105  degrees),  a  normal  thickness  of  tli^' 
symphysis,  and  a  normal  height  of  the  promontory. 

When  the  height  of  the  symphysis  is  greater  than  l^  inclu^ 
(4  cm.),  about  'j  inch  (2  cm.)  should  l)e  deducted  from  tlic 
diagonal  conjugate. 

The  true  conjiu/dte  may  be  measured  with  almost  perfect 
accuracy  by  means  of  a  special  pelvimeter  invented  by  llir>t, 

Fig.  102. 


Internal  pelvimetry.   Measuring  the  diagonal  conjugate  with  the  hands.    (Jewctt.) 


of  Philadelphia.  Hirst's  measurement  is  from  the  promoiiduv 
to  a  })oint  one-eighth  of  an  inch  below  the  uj)per,  outer  boidf  r 
of  the  symphysis  pubis.  Plirst's  pelvimeter  corisists  of  a  inii<i, 
straight  rod,  to  which  is  attached  a  movable  bar  haviuu  a 
slight  curve. 

The  physician  having  placed  the  middle  finger  of  the  hft 
hand  uj)on  the  promontory,  the  tip  of  the  straight  end  of  the 
pelvimeter  is  pushed  into  place  alongside,  where  he  hoKU  it 
lirndy,  while  an  assistant  adjusts  the  tip  of  the  moval)!*'  liar 
over  a  point  one-eighth  of  an  inch  below  the  outer  u|t|M'r 
border  of  the  svmj)hvsis.  This  bar  is  then  screwed  ti<i:lit.  the 
pelvimeter  removed,  and  the  distance  between  the  tij)s  iik  a<- 
ured  by  means  of  a  tape.     The  thickness  of  the  symph\  '-^ 


PELVES  ABNORMAL   IN  SIZE.  275) 

j»iil)is  is  then  measured  l)y  t]:;iii(liiiji;  oiu;  tip  of  tiie  pelviiiictcr, 
iitrodiieed  into  tiie  vn<i:ina,  to  a  point  one-ei<:^iitii  of  an  inch 
iVoni  the  toj) ;  the  outer  bar  is  then  adjusted  to  tiie  same  jioint 
;ts  before  and  screwed  tiglit,  and  tiie  distance  Ix'tween  tlie  tips 
measured  after  the  pelvimeter  has  been  witiuh-awn. 

Pelves  Normally  Proportioned  but  Abnormal  in  Size. 

Unifonnly  Enlarged  Pelvis  (Justomajor). 

Definition:  This  form  of  pelvis  preserves  all  the  characters 
of  the  normal,  but  all  its  measurements  are  increased.  It  is 
LTcnerallv  to  be  found  in  women  of  <rreat  stature,  thouirii  it  is 
met  with  oecasionallv  in  women  below  the  medium  liciirlit. 

Diagnosis:  All  the  measurements  are  found  to  be  in  excess 
(if  the  normal  while  })reserving  their  relative  proportion. 

Influence  on  pregnancy  and  labor:  During  pregnancy  the 
uterus  tends  to  remain  longer  in  the  ))elvis  tiian  in  the  normal 
(•(ii)dition,  thus  giving  rise  to  disturl)ances  of  the  bladder  and 
of  the  rectiun.  l^^or  the  same  reason  the  pressure-symj)toms 
ill  the  latter  part  of  j)regnancy  are  often  severe,  and  may 
render  lociMuotion  diflicult. 

The  condition  predisposes  to  precij)itate  delivery.  The 
iinj)erfect  resistance  oifered  to  the  head  in  its  descent  may 
lead  to  loss  of  flexion,  and  thus  retard  rotation. 

Uniformly  Contracted   Pelvis  (Justominor). 

Definition  :  Tn  this  type  of  pelvis  the  form  is  preserved,  but 
its  size  is  diminished. 

Three  varieties  of  the  justominor  jX'lvis  are  usually  de- 
scribed :  of  these,  the  most  common  is  the  juvenile,  in  which 
the  bones  are  small  and  slender ;  the  inasenliiie,  in  which  the 
hones  are  heavy  and  thick  ;  and  the  <hr<(rf,  or  pelvis  nana,  in 
which  the  bones  are  thin  and  fragile,  and  the  cartilaginous 
junctions  between  the  constituents  of  the  ossa  innominata  are 
retained. 

Occurrence:  The  uniformlv  contracted  pelvis  is  usuallv  to 
be  found  in  under-size<l  women,  though  it  may  be  met  with 
in  women  of  average  height,  or  even  in   tall   women.     It  is 


280 


PATHOLOGY  OF  LAliOR. 


most  commonly  met  vvitli  in   Aiiiorica  in  sliop-  and  factor\~ 
girls. 

Etiology:  The  causation  of  tlie  justominor  jujlvis  has  jk.: 
been  satisfactorily  explained.     Jt  is  generally  the  result  oi 
arrested  development  due  to  unfavorable  hygienic  surround- 
ings and  bad  nutrition  in  early  life. 

Characteristics:  The  generally  contracted  pelvis  aiiproaeln - 
the  infantile  in  type  (Fig.  lO^i).     The  ahe  of  the  sacrum  are 

Fig.  103. 


Generally  oontrnotcd  dwarf  pelvis.    (After  Wiiickel.) 


narrow,  while  the  sacrum  itself  is  sliort  and  has  lessened  for 
Avard  inclination  as  compared  with  the  normal.  The  proniun- 
tory  is  high  but  not  prominent.  The  ])ubic  bones  and  syiti- 
physis  have  a  lessened  inclination  outward.  Thus  when  tlic 
patient  stands  erect  the  inclination  of  the  pelvic  entrance  to 
the  abdominal  axis  makes  a  more  obtuse  angle  than  would  he 
the  case  in  a  normal  jielvis  (Fig.  104). 

Usually  the  contraction  is  not  very  great.  The  conjugate 
diameter  is  seldom  below  9  cm.  (3^  inches). 

Diagnosis:  Careful  pelvimetry  will  show  that  all  the  nioas- 
urements  are  below  normal,  with  the  exception  possibly  of  the 
external  conjugate  diameter,  wliich  is  longer  than  would  l»e 


PELVES  AnXOEMAL   L\  SIZE. 


281 


.'xpcrted,  on  account  of  tlio  posterior  position  and  lessened 
inclination  forward  of  tiie  sacrum.  In  tliis  form  of  contracted 
[K'lvis  tlie  measurement  of  tlie  pelvic  circumference  is  gener- 
,illy  far  helow  the  normal,  i)()  cm.  ('^').j  inches). 

Influence  of  labor :  The  increased  resistance  ollered  to  the 
descent  of  the  head  results  in  Hexion  heint;  more  marked  tlian 
't  is  in  the  normal  pelvis.  The  head  generally  enters  the  hrim 
111  the  oblique  diameter. 

In  hrccc/i  cdHcs  the  child's  head  nnist  be  well  Hexed,  by  the 
(ij)erutor  putting  his  Hnger  in  its  mouth  and  drawing  down 

Fig.  104. 


Diagram  showinp  difference  between  normal  and  jnstominor  pelvis  on  vertical 
mesial  section.    Black,  normal.     Red,  justomiTior. 


the  chin  before  an  attempt  is  made  to  secure  engagement  in 
tlie  brim. 

fjihf))'  ix  HHiKiUji  j)r(>lo)ifj<'(J,  and  the  head  undergoes  much 
111  )nlding,  the  caput  succedaneum  being  unusually  large. 
1  hi;  suboccipitobregmatic  diameter  of  the  head  is  com- 
jtressed  and  the  occipitomental  elongated  (Fig.   105). 

Treatment:  If  the  hea<l  is  advancing  under  the  influence 
•  •r  uterine  action,  no  interference  is  calh^l  for.  The  patient's 
strength  must  be  sustained  by  a|)])ropriate  nourishment,  and 
opium  may  be  used  hypodermically  to  relieve  her  sufferings. 
l*l(Mity  of  time  must  be  allowed  to  secure  good  moulding  of 
the  head. 


282 


PATIIOLOCIY  or  L.JiOIi. 


Fio.  105. 


Wlicn  labor  in  dctdi/cd  and  advaiioo  oftlio  lioad  ccasi^s,  tlur, 
forceps  .should  he  triL'd.     The  axis-traction  iorcej)s  should  h, 

employed.       As  a   rule,   when  tlic 
contract  On   is  not  over  one  centi 
metre  the  head  can  he  extracted  ii 
it  he  fairly   soft  and   has  heen  ;il- 
lowed  to  hecome  well  moulded. 

If  moderate  ettbrts  at  extractiun 
with  the  forceps  fail  to  hrini;  jihdiii 
advance  of  the  head  and  the  eliilil 
is  still  living,  fii/iiiphi/siotomij  should 
be  performed. 

Version  is  not  to  be  recommended 
on  account  of  the  difficulty  in  seciii-- 
ing  the  proper  amount  <>f  He\i(^n 
DiaRram  showinpr  head  iiii-     n(!cessary  to  permit  the  CUiJ^agenicill 

iiKiiildcd  ami  inoiildud  by  lalxir  p    ,i         /•■  •         i         i  •'      fi  i 

ill  ajiist()iiiiii..icasf.  ot  tlic  aiter-comiug  head  m  tlie  pd- 

Red,  mouldi'd.  VIC    DUm. 


Pelves  with  Anomalies  of  Size,  Shape,  Inclination;  or 

Combinations  of  These. 


Mir^cT  Developmental  Peculiarities. 

Masculine  pelvis:  Tn  this  pelvis  the  bones  are  heavy  and 
strong,  and  the  whole  ])elvis  is  masculine  in  character. 

Labor  may  be  ])rolonge(l  and  difficult  on  account  of  dehiy 
either  in  the  brim  or  the  outlet.  Forceps  are  frequently  re- 
quired to  accomplish  delivery. 

Shallow  pelvis :  The  distance  between  the  brim  and  tlie 
outlet  is  relatively  less  in  this  form  of  pelvis  than  in  tlie 
normal.  As  a  rule,  labor  is  easy,  though  occasionally  forcejo 
are  required. 

Deep  pelvis:  There  is  an  abnormal  increase  in  tlie  distance 
between  the  inlet  and  the  outlet  in  this  form  of  ])elvis.  Pro- 
vided the  diameters  are  normal,  labor  is  not  interfered  with. 

Funnel-shaped  pelvis:  In  this  form  of  pelvis  the  .sacrum  is 
narrow  and  has  little  perpendicular  curve,  and  thus  the  depth 
of  the  canal  is  increased  (Fig.  lOG).  In  this  form  of  pelvis 
the  contraction  is  nicst  marked  at  the  outlet,  and  may  Ix'  in 


VKI.VES    WITH  ANOMALIES  OF  SIZE,    ETC. 


28.'} 


\\\i\  anteroposterior  (liainctoi',  or    in    llic  latoi'al,  or  in   hotli. 
Tlic  pelvis  tlius  approaclies  tlic  niascuiinc  in  type. 

Injlunur  <,ii  Lahor :  Tlic  lueelianisin  of  lai»or  is  interfered 
will)  and  tlie  head  tends  to  Ix'cotne  extended  in  tlie  cavity  of 
;lie  pelvis;  tliiis  backward  rotation  of  tlie  oceij)nt  is  likely  to 
oei'ur.  Jiahor  is  usually  prolonged,  tlie  delay  oceurrinu-  v.  lien 
I  he  head  is  at  the  outlet.  There  is  j^nater  risk  of  extensive 
rupture  of  the  ju'rineinn.  The  soft  parts  at  the  ju'lvic  outlet 
are  likely  to  be  injured  by  undue  pressure  of  the  head. 

Flu.  100. 


Funnt'l-shaped  pelvis.    (After  Winokel.) 

Treatment:  Tn  the  lesser  fjrades  of  contraction  the  'woman 
may  be  delivered  spontaneously  or  l)y  force])s.  In  the  higher 
LH'ades  the  C^esarean  ojieration  may  be  recjuired.  Sym])hy- 
siotomy  may  be  employed  Avhen  the  contraction  in  the  outlet 
is  not  marked  and  efforts  at  extraction  by  means  of  the  for- 
ceps fail. 

Flat  Pelves. 

Shortening  of  the  conjugate  diameter  of  the  brim  is  the 
main  characteristic  of  flat  pelves. 

Simple  Flat  Pelves;  Non-mchitic. 

Schroder  states  that  this  variety  of  deformed  ])elvis  is  more 
frequently    seen   in    Euro})e    than    all    the   other  forms    put 


liSl 


I'ATIIOIJXIY  OF  LAIlon. 


tojj^cllicr.      In  Anicrica  th((  sliiij)l('  flat,  and  tlic  ^;('n('i'allv  coii 
tractod,  ai'c;  tlic  two  varii^tics  of  pcKic  (Icroniiity   mo.st  lic- 
(jiictitly  met  witli. 

Hirst,  ill  a  scries  of  .'{KJ  pelves  in  women  of  American 
hirtli,  found  flatteninfj^  to  exist  in  5.<)  j)cr  cent.  Davis,  in  a 
series  of  1 1224  pelves,  found   the  simple   Hat    in  5.7  \)vv  cciii. 

Characteristics:  The  sacrum  is  small,  and  pressed  down- 
ward and  forward  between  the  iliac  bones;  as  it  is  not  rotatnl 

Fid.  107. 


Flat  nonrachitic  pelvis.    (After  Kleinwiichter.) 

forward  on  its  transverse  diameter,  the  anteroposterior  diam- 
eter of  the  pelvis  is  therefore  contracted  throughout  its  wlinlc 
extent.  The  transverse  diameter  remains  as  great  as  in  the 
normal  pelvis  (Fig.  107). 

Frequently  in  flat  pelves  there  is  a  dnuhlc  prnmoiifori/,  m) 
that  a  line  drawn  between  the  second  sacral  vertebra  and  the 
symphysis  is  often  as  short  as,  or  shorter  than,  the  true  con- 
jugate. 


PKLVKS   WITH  AS OM A  LIES  OF  i>lZh\   ETC         285 

'PI)o  <h'(/nr  of  coiitrdcdon  is  usually  not  ^rcat,  as  it  is  rarely 
lu'low  8  em.  [li^  iiiclies),  and  usually  not  iiiidcr  \K')  cm.  (oij 
inclics). 

Etiology:  Tlic  coiKlitioii  is  usually  conjiciiital,  ihoii^di  hard 
work  in  yontli,  too  early  walking',  and  e.\(!essi\e  standin;^  on 
till'  feet  may  l)e  mentioned  as  eansative  fju^tors. 

Diagnosis:  This  pelvis  may  he  t'onnd  in  small  or  in  Iarjr<' 
women.  There  i.s  nsnally  iK^thiiiL:;  in  the  patient's  history  or 
appearance  to  siifrij^est  the  deformity,  nnle»  >he  has  had  dilli- 
culty  in  previous  labors.  \W  pelvimetry  the  transverM' 
measnrements  will  ho  fonnd  to  he  normal,  while  the  antero- 
posterior diameter  will  be  diminished. 


The  Flat  Rachitic   Pel r is. 

Characteristics:  Rachitis  loads  to  increased  condensation  in 
the  hones;  hc^nce  in  the  flat  rachitic  pelvis  they  are  heavier, 
thicker,  and  somewhat  smaller  than  in  the  normal.  Tiie 
sacrum   is  wider  than   in   the  normal   pelvis. 

The  i/inc  crests  are  more  or  less  everted  at  their  anterior 
ends,  so  that  the  interspinal  diameter  is  eipial  to  or  lireater 
than  the  intercristal.  "^I'he  ilia  are  flattened,  so  that  the  fossie 
are  not  so  distinctly  hollowed  ont  nor  are  the  iliac  winujs  as 
(•xj)anded  as  in  the  normal  pelvis.  The  y>c/r/c  hriin  is  kidney- 
shaped,  not  heart-shapc.'d,  as  in  the  normal  pelvis.  '\\w  coii- 
jii(/(itc  is  diminished  ;  and  the  traiis- 
rcrsc  (lidmetcr  relatively  or  ahsolntely 
increased.  At  the  outlet  the  transverse 
diameter  may  he  widened  and  the 
antero])()sterior  he  eitluir  normal  or 
increased  (Fig.   108). 

The  pnhic  arch  is  wider  than  nor- 
mal, and  the  symphysis  is  deejx'r 
and  is  rotated  on  its  transverse 
•  liameter,  so  that  its  npj)er  border 
converges  toward  the  j)romontorv. 
Tims  the  relation  of  the  trne  conjngate 
to  the  diasxonal  conjngate  is  not  the  same  as  in  the  normal 
pelvis  (Fig.  109). 


I)ia;,'riiiii  shdwiiiu  outline 
of  liriiii  !>('  iKiriiml  and  of 
Hal  racliitic  [)clvi.s. 

Hhick,  normal.     Itud,  flat. 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


J^:^ 
% 


// 


y. 


X*   >>    ,..  'mis- 


v.. 


1.0 


I.I 


11.25 


1^ 

no 


US 

US 

Ui 


1^  IIM 

tei  Ilia 

2.0 


■  40 


14  mil  1.6 


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PhotogranFiic 

Sciences 

CorpoMon 


23  WEST  MAIN  STREET 

WEBSTER, NY.  M580 

(716)  873-4503 


28  (i 


PATHOLOGY  OF  LABOR. 


Fig.  lOU. 


In  tlu'  rachitic  })elvis  the  coxjiif/dta  vci'((  may  be  diniiiiislK  (i 

to  any  extent,  dcjicndin^-  on  iIk 
(lc<>;rcc  of  dcfoi-niity  pi'o.-cMt, 

Etiology:   liadiitis  in  its  cjnU 
stages  causes  a   softening  (»f  tin 
bones  and  bgaincnts.    Tlic  wcigln 
of  the    body    tends    to    pnsii    tin 
])roniont()ry  of  the  sacnnn  dowii- 
Mard  and  forward  ;  tiiis  causes  ;i 
rotation    of    the    sacnnn    on     ii- 
transv'  rse    diameter,    and    teiids 
to  eh    ,  te  the   h)\vei    part  of  tlii> 
bone  aiivl  the  coccyx  uj)\vard  and 
backward.     Thestr(»ng  liganuiits 
attaclied  to  the  h)wer  part  of  ilic 
sacrnni     prevent     its     niovenicni 
u{)war(l  and    l)ackwar(l,  and    tin 
residt  is  a  sharj»  bending  of  tin' 

nin>:mm  sliowinp  (lillVrcnoc  be-       Ixino    pnxhiccd    ill     tlie    n('iuhi)or- 
twfi'ii  iioniml   iiiid  nichitic  iu'lvis       ,         i       n     i        /«  i  i 

on  vtiti'iii  niLsiai  siciiim.  Iiood  oi    the  lourth   saci'al   VCltc- 

l)ra. 

iJesides  tlie  weigiit  of  tlie  body,  tlie  action  of  the  imischs 
attached  to  the  jH'lvis  lielj)s  to  bring  about  the  (k'ibrniity.  Tlic 
increased  sepai'ation  of  tiie  ischial  tuberosities  is  thie  to  tlic 
action  of  the  abchictor  and  rotator  niusck's  of  the  tliigiis.  'I'hc 
(k'gree  of  (k'formity  pnxhiccd  by  ra<'hitis  depends  on  tlie  dat( 
of  its  appearance,  its  severity,  its  duration,  and  the  habits  ol' 
the  child. 

Diagnosis :  The  history  of  the  woman,  her  appearance,  and 
the  examination  and  measurements  of  her  pelvis  will  permit 
the  establishment  of  a  diagnosis. 

The  rachitic  woman  is  usually  nnder-sized.  She  may  li:i\i' 
a  s(pia re-shaped  head  or  deformed  thorax  (pigeon-breast),  bead- 
ing of  the  ribs,  and  curved  long  bones,  which  may  beenlarg((l 
at  the  ends.  When  she  lies  on  a  Hat  surface  with  the  liiiili- 
well  extended  lordosis  is  generally  jiresent. 

Pi'lric  invdSKi'onnif  will  show  that  the  relation  of  the  spines 
and  crests  of  the  ilia  is  altered.  The  external  conjugate  ami 
the  diagonal  conjugate  diameters  will  be  found  diminished.  On 
account  of  the  increased  depth  of  the  symphysis  and  the  divci- 


PELVES    WITH  A  SO  MA  LIES   OF  SIZE,   ETC. 


287 


iTcncc  of  its  lower  mar^iii,  ^  iiK-h  (2  cm.)  wnx^i  bo  dcdiicttHl 
iVoin  the  diagonal  conjugate,  instead  of  the  average  j?  inch 
( 1.75  cm.). 

Care  must  he  taken  to  ascertain  if  a  doiihlr  pr(»notil())i/  is 
present;  and  if  so,  the  conjugate  should  he  measured  from  the 
projection  of  the  sacrum  which  is  nearer  the  symphysis. 

j\ [cell (til is}ii  of  Labor  in    Flat   Pr/irs. 

The  contracted  condition  of  the  conjugate  j)revents  the 
entrance  into  the  jwlvic  inlet  of  the  j)resenting  part  ;  hence  the 
ahdonien   is  usually   more  or  less  pendulous. 

The  |)resenting  part,  if  it  is  the  head,  is  usually  found  at  the 
onset  of  lahor  to  he  restintj  in  one  or  otiier  iliac  los>a  ;  or  it 
may  he  tirndy  pressed  down  upon  the  hrim  in  a  transverse 
position,  so  that  its  longest  diameter  is  accommodated  to  the 
li ingest  diameter  of  the  jjclvic  inlet. 

Malpresentations  are  common,  and  piolapse  of  the  coi\;  and 
of  the  extremities  is  not  infre(|Uent. 

The  first  stage  of  hihor  is  usually  ])rolonged,  because  of  the 
non-descent  of  the  head.  The  membranes  protrude  from  the 
OS  in  a  cylindrical  pouch.  TTnfortunatelv  the  \)\\\i  of  waters 
nsnally  ruptures  early  ;  an<l  in  this  case  dilatation  can  ordy  be 
ctfccted  by  a  retraction  of  the  c(!rvix   over  the  head. 

In  the  second  stage  of  labor  the  desc-ent  of  the  head  is 
nsistcd  by  the  projection  of  the  sacral  ])romontory.  Thus  the 
occiput  is  pushed  to  one  side  till  it  conies  into  contact  with  the 
lateral  brim  of  the  pelvis,  the  iliopectineal  line,  where  it  is 
arrested.  The  sinciput  not  being  resisted,  then  desc(>nds,  and 
thus  extension  of  the  head  occurs  ;  this  brings  the  small  bi- 
tcni]>oral,  insteatl  of  the  larger  biparietal,  diiuneter  of  the  lu'ad 
into  relation  with  the  contracted  conjugate. 

The  movement  "rounding  the  promontory"  then  takes 
place.  The  posterior  parietal  bone  becomes  arn'sted  on  the 
ptomontory,  so  that  the  head  becomes  oblicpiely  displaced  by 
tm-ning  on  Its  anteroj)oslerior  diameter.  Thus  the  sagittal 
>iitiu-e,  instead  of  remaining  in  the  middle  of  the  ju'lvic  inlet, 
:ipj)roaches  the  promontory,  as  the  anterior  parietal  bone  slips 
past  tlie  uj)per  border  of  the  symphysis  and  enters  the  cavity 
i»i  the  pelvis.     Then  the  posterior  parietal  bone  slips  past  the 


>^- 


288 


PATHOLOGY  OF  LABOR. 


Fic;.  110. 


0 


pronioiilorv,  and  the  licad  outers  the  pelvic  cavity  in  an  extcndc.! 
position  (Fig.  110). 

Once  tiie  obstruction  at  the  superior  strait  is  passed,  tin 
head  usnally  descends  with  ease  and  rapidity,  tiie  rest  of  tin 
nieclianisin  going  on  normally.  Occasionally  rotation  of  tli^ 
head  fails,  and  owing  to  the  widtii  of  the  transverse  diani'ti  i 
of  the  ])elvis  it  is  expelled  from  the  vnlva  in  its  original  ti-an  - 
verse  or  in  an  ohiiqne  position. 

Head-moulding:     The  caput  snccedaneimi  is   gencrallv  wa 

exagg<'rated.  Usnally  the  cliildV 
head  shows  what  is  known  as  tin- 
"  j)romont()ry  mark."  This  nuiv  1m' 
only  a  red  mark  on  the  parietal  iv- 
gion,  between  tiie  anterior  fontiuiciji' 
and  the  parietal  eminence  which  was 
in  contact  with  the  promontory.  Or- 
Moulding  of  head  duriiiK  casionally  thcrc  mav  be  an  actual  dc- 
Kif  ""'""'''''  ""'  ™""'"'     pression  of  the  i)arietal   bone  in  tliis 

region.  Sometimes  a  gnttcr-lil-c 
groove  may  be  noted  in  a  lin(^  running  outward  and  forwaid 
on  the  child's  skull.  Usually  the  posterior  parietal  bone  i-; 
depressed  below  the  anterior,  which  overlaps  it  at  the  sagittal 
suture. 

Treatment  of  Lahor  in   Flat  Pelres. 

Care  should  he  taken  to  keep  the  membranes  intact  as  Iniitr 
as  possible,  by  keeping  the  pntient  in  bed  during  the  first  stanv 
of  labor,  and  by  warning  her  Ttrainst  "bearing  down"  dnriiii: 
the  pains. 

If  the  conjugate  is  not  greatly  diminished,  the  head  will 
usually  engage,  provided  it  be  given  ])lenty  of  time  to  nionM. 
To  this  end  the  uterine  contractions  should  be  controlled  by 
means  of  hypodermic  mjections  of  niorjihine  or  of  Battley's  S(ilu- 
tion.  The  patient's  strength  should  be  maintained  by  ;lio 
administration  of  nourishing  broths,  egg-noggs,  ect.  If  tlio 
child's  head  be  not  iniduly  ossified,  this  treatment  in  the  lai^e 
proportion  of  cases  will  j>rove  successful. 

Should  the  head  not  descend,  interference  should  not  \>o 
delayed  too  long,  for  there  is  danger  that  the  pressure  of  ilio 
head  may  residt  iii  , necrosis  of  the  cervical   tissue   over   the 


PELVES    WITH  A  yoM  A  LIES  OF  SIZE,  ETC.  2^1) 

promontory  and  of  the  anterior  va(i:iiial  wall   behind  the  .syni- 
[ihysis. 

J)elivery  hy  the  eMij)l()ynu'nt  of  axis-traetion  fitrccjis  tnu^t 
;hen  bo  attempted  ;  for  this  ()j)eration  the  patient  shonld  be 
|ilac'ed  in  \\  ulchci's  position.  JShould  the  Ibreeps  operation 
fail,  delivoiy  of  a  iivinjij  child  ean  only  be  effected  by  recoiii'se 
to  sym])hysiotomy  or  to  C'tusarean  section. 

Obliquely  Contracted  Pelves. 

()l)li(juely  contracted  ])elves  result  I'rom  : 

(«)  Imperfect  develo})ment  of  one  sacral  ala; 

Via.  111. 


Sin<,My  (il)li(HU'ly  coiitriictiMl  ]p(i\  is.    (AftiT  ^■■ill(■kel.) 


(h)   Imperfect  or  abolished  nse  of  one  limb;  or 
(/')   Lateral  ciu'vatnre  of  the  spine. 

19_0bst. 


290 


PATHOLOGY  OF  LABOR, 


fn  tlicso  pelves  tlu;  jK'lvic  inlet  1ms  an  oval  shape,  with  tli 
small  point  directed  to  the  atrophied  side  of  the  pelvis  {Fvj;. 

111). 

The  diagnosis  is  based  upon  the  history  of  the  woman,  an  I 
a  earefiil  examination  and  measurement  of  her  pelvis. 

Influence  on  labor:  The  mechanism  of  the  head  in  passiiiL: 
throni^h  an  ()l)li(jnely  contracted  })elvis  is  the  same  as  in  tin' 
case  of  a  justominor  pelvis.     The  head  usually  enters  the  briin 


Fig.  112. 


Transversely  contracted  pelvis.    (After  E.  Martin.) 

in  extreme  flexion,  with  its  long  diameter  in  relation  to  the 
long,  oblique  diameter  of  the  pelvis.  The  long,  ol)Iii|iii' 
diameter  is  usually  that  of  the  diseased  side.  As  the  hcnl 
descends  rotation  may  fail  and  the  occij)ut  may  turn  toward 
the  sacrum. 

Treatment:  The  long  diameter  of  the  head  should  alw:ivs 
be  brought  into  relationshij)  with  the  long  oblique  diameter  of 
the  pelvis  by  manual  rotation,  should  Nature  have  failed  to 
accomplish  this  before  the  onset  of  labor. 

Should  descent  of  the  head  be  delayed,  the  axis-traction 
forceps  should  be  tried.  Should  these  fail,  Cfesarean  section  is 
the  oidy  operation  available. 

Should  the  condition  be  diagno.sed  early  in  pregnancy,  pn-- 


PELV/'JS    WITH  ANOMALIES  OF  SIZE,   ETC.  291 

iiiiitmv  liihor  may  ho  iiulucwl,  provided  the  deformity  of  the 
iK'lvis  is  not  extreme. 

Transversely  Contracted  Pelves  ( Fig.  1 1 2). 

Transverse  contraetion  of  the  pelvis  results  from: 
{(i)  I  nipt' r  feci  (hvclopmcnt  of  both  sacntl  ahv  (Robert  pelvis): 
{/>)  Ki/plio.si,s  of  the  sj)inc. 
This  is  a  very  rare  (U'formity. 

As  delivery  "per  vias  naturales"  is  impossible,  Caesarean 
.^ection  must  be  employed. 

Compressed  Pelves. 

Two  varieties  of  compressed  peKes  have  been  described,  the 
liiiilacotiU'on  and  tiie  pscudomalacoKffon. 

3f<ll((C0StC0)L 

Characteristics  :  The  wlioie  pelvis  is  greatly  altered  in  shape. 
There  is  a  marked  bending  of  the  iliac  wings,  the  anterior 
^llperior  spines  turiiing  inward.     The  pelvic  brim  is  triradiate, 


Fk;.  113. 


Fig.  114. 


I'iiigram  sliowiiip  (liffcronre  he- 
twrcn  normal  and  nialacosteoii  jiel- 
vi.-<  on  viTtical  mesial  section. 

Hlaelf.  normal. 
Red,  malacosteon. 


Diagram  showiTip:  outliiu'  of  brim  of  normal 
and  of  malacosteon  pelvis. 
Black,  normal. 
Red,  malacosteon. 


202 


I'ATJlOLOa^  OF  LAIiOn. 


owinti:  to  flic  proinontory  and  th<;  aoetal)iila  \)viurr  appiox- 
iiiiatcd.  'I'lic  piihic  hones  arc  close  toirctlicr  and  pi'ojcct  a>  ,i 
hcak.  'I'lic  curve  of  the  sacrum  is  ij^reatly  ex auge rated  ain! 
the  coccyx  }»oints  upward  into  the  pelvic  canal  (Fi^s.  ll.'>,  11  I 
and  1  \i)). 

Etiology:  'i'he  condition  is  l)rou<;ht  ahout  hy  ^reat  softenin- 
of  the  hones  resullin<;  from  osteomalacia  (mollities  ossiiuiii. 
This  disease  is  met  with  chiefly  in  Euro[)e,  and  is  chnracteri/i  <! 

Fig.  115. 


Malacostcon  pelvis,  seen  from  above.    (After  Winckel.) 

by  a  removal  of  the  lime  salts  from  the  l)ones.  It  usuallv 
develops  during  the  puer])erium,  but  also  occurs  in  ])regnaii(v. 
The  deformity  results  from  transmission  of  the  weiirht  of  the 
body  through  the  p(>lvis  to  the  lower  limbs. 

Diagnosis:  This  is  based  npcsn  the  history  of  the  wnmaii 
and  an  examination  of  the  pelvis. 

Treatment :  When  the  bones  are  soft  delivery  may  be  efticli  il 
by  means  of  forceps  ;  when  the  bones  are  hard  and  the  deronn- 
ity  ))ermanent,  Ca3sarean  section  must  be  performed  should  tlic 
j)clvic  contraction  be  extreme. 

IWuiJoutdlcK'oxffon  (Rachitic). 

This  deformity  of  the  pelvis,  produced  by  severe  rachitis, 
may  closely  apj)roximate  that  produced  by  osteomalacia. 


PELVES    WITH  ANOMALIES  OF  SIZE,    ETC.  2S>;> 

Wiiilo  the  (k'toi'inlly  of  tlic  tnio  [u'lvis  is  very  imicli  as  in 
the  iimlacostt'on,  the  iliac  wings  aiv  widoiy  sepaniU.'d  as  in  tlu' 
typical  rachitic  condition. 

Spondylolisthetic    Pelves. 

Definition:  'I'lic  name  applied  to  this  variety  of  pelvic  <lc- 
rormity  indicates  the  (;ondition — "'  spondylolisthesis,"  a  -ilipping 
down  of  the  vertebra,  heing  derived  IVoni  a7:6uo'JAu;,  "  ver- 
tebra," and  okiath^ac;,  "  a  slip})ing  down." 


Spondylolisthetic  pelvis.    (After  K.  Martin.) 

The  deformity  is  due  to  a  dislocation  of  the  last  lnnil)ar 
vertebra  in  front  of  the  sacrnin.  The  body  of  the  former  is 
usually  found  to  have;  slipped  down  in  front  of  the  first  sacral 
vertebra,  to  which  it  has  become  attached  l)y  bony  union.  An 
exaggerated  lordosis  is  produced,  so  that  two  or  more  of  the 
lumbar  vertebra?  descend  into  the  pelvic  inlet  and  obstruct  its 
anteroposterior  diameter.  The  sacrum  is  pushed  downward 
and  backward,  and  to  compen.sate  this  the  anterior  half  of  the 


2H4  PATIlOLOar  OF  LABOli. 

pelvis  is  raised,  so  that  the  heiglit  of  tlic  symphysis  is  increased 

(Fi^^  11«). 

Tlie  pelvic  inlet  is  thus  diniiiiished  both  laterally  and  anlern- 

postei'iorly. 

Etiology:    Injury,   disease,  and    developmental    delects   an 
usually  mentioned  as  predisj)osing  causes. 

The  diagnosis  is  somewhat  dillicult  uidess  the  condition  i- 
well  marked.  The  stature  of  the  woman  is  diminished,  iukI 
the  ribs  may  come  into  actual  contact  with  the  iliac  crot-. 
Lordosis  is  extreme  and  the  shoulders  are  carried  well  hack 
when  the  patient  is  erect.  The  posterior  suj)erior  iliac  spiui- 
are  widely  separated.  The  pelvic  inclination  is  altered,  so  tli;i! 
the  vulvar  region  is  carried  somewhat  forward. 

InteiiKil  examination  I'eveals  the  projection  of  the  luinliai' 
vertebrte.  It  may  be  possible  to  feel  the  lower  end  of  the 
aorta  j)ulsating. 

Treatment:  The  deformity  is  of  the  nature  of  a  flattening 
of  the  pelvis,  so  that  the  mechanism  of  labor  resembles  thai 
which  occurs  in  the  flat  rachitic  pelvis.  The  obstruction  to 
labor  dej)ends  entirely  upon  the  ])rojcction  of  the  hnnbar  ver- 
tebra. The  treatment  is  conducted  on  the  same  lines  as  in  Hat 
pelvis. 

Pelves  Distorted  by  Injuries,  Tumors,  or  Disease. 

Luxation  of  tlie  femur:  This  condition,  which  is  u>uall\ 
congenital,  rarely  produces  such  deformity  of  the  pelvis  a- 
s<'rio',isly  to  obstruct  labor. 

Tumors:  T'^9  commonest  tumors  which  occur  in  connection 
with  the  ])elvis  are  crnstoscs  of  the  joints.  Fibroma,  sarcoma. 
carcinoma,  and  (Michondroma  of  the  ])elvic  bones  may  distoit 
the  pelvis  and  so  lead  to  obstruction  (Fig.  117). 

Treatment:  When  the  growth  is  not  excessive  delivery  1»\ 
the  natural  passages  may  be  possible.  When  such  is  not  ilic 
case  Csesarean  section  must  be  performed.  Symphysiotoiii\ 
may  be  employed  in  suitable  cases,  when  the  sacro-iliac  joints 
are  not  involved  in  the  tumor. 

Fractures  of  the  pelvis:  Deformity  the  result  of  fracture  ol' 
the  pelvic  bones  is  rare. 

Separation  of  the  symphysis  pubis :  This  accident  may  occiw 


rKLVES    WITH  ANOMALIES  OF  SIZE,   ETC. 


oor; 


95 


as  IX  result  of^ioat  force  l)ein<j;  exerted  in  tlie  extraetiiui  ol'  tlie 
head  1)V  means  ol' forceps,  oi'  after  vei>ion  lias  been  pel  loiMiied. 
Osteomalacia,  rachitis,  syj)liilis,  and  tiihei'ciiiosis,  or  any  |)r(t- 
lound  cachexia,  may  predispose  to  the  occnrrenci-  of  this  aci'i- 
ilent. 

DidgnoaiH :  The  ])atient  fjjenerally  com|)lains  of  sharp  pain  at 
tlic!  moment  of  sej)aration  of  the  joint.  The  con«lition  may  he 
iccoy-nized  l)v  introdncinti*  the  index-fmijccr  into  the  vagina 
behind  the  joint  and  grasjying  it  between  the  tinker  and  tin. nib. 

Fig.   117. 


Malignant  growth  of  posterior  wall  of  jiclvis  wliicli  nccossitated  Ca-harean  section 

in  a  case  of  i)r.  Canierdn. 

Ti'catmeni:  This  consists  in  the  ap})lication  of  a  firm  pelvic 
uirdle  as  recommended  for  use  after  the  operation  of  sym- 
|>liysiotomy. 

Anchylosis  of  pelvic  joints:  This  condition  may  affect  any 
of  the  pelvic  joints.  When  the  symi)hysis  is  att'ected  it  lias 
l)nt  little  influence  on  labor.  Anchylosis  of  the  sacro-iliac 
joints  may  result  in  serious  pelvic  deformity.  Not  uncom- 
monly the  sacrococcyj:^eal  joint  is  affected,  in  which  case  ob- 
struction may  occur  at  the  outlet.  Fracture  of  the  coccyx  is 
tiic  usual  result. 


21)0 


PATHOLOGY  OF  LAliOli. 


Split  pelvis:  Want  of  ('(iiiiplctc  (Ic.'vcldjuiicnt  of  tlic  aiitcrinr 
wall  «»f"  iIk!  jic'lvis  n-sults  in  this  condition.  It  docs  not  caii-f 
any  olistriK.'tion  to  labor,  but  is  likely  to  be  associated  with 
precipitate  delivery. 

Pelvic  Deformities  Due  to  Spinal  Curvature. 

Kyphosis:  'I'lie  de<ijree  of  j)clvic  (lef(>rniity  resulting;  from 
kyphosis  dep(!nds  on  the  situation  of  the  hump;  the  nearer  tlii- 
is  to  the  sa(!niin  the  greater  ':.  the  deformity  of  the  ju'lvi-. 
(jrcnerally  th(^  kyphosis  occurs  about  the  junction  of  the  doixil 
and   lumbar  vertebne. 

Trcctiiind:  i^  the  degree  of  contraction  is  sligiit,  labor  i> 
us'ially  easy.     Tiiere  exists  an  old  saying  that  "  hunchl)acks 

Fig.  118. 


Lordotic  pelvis.    (After  Kleinwiichter.) 


have  easy  labors."  AVhen  delay  takes  ])]ace  fofoeps  may  be 
required  to  effect  delivery.  In  extreme  contraction  the 
Oesarean  operation  is  demanded. 

Lordosis  is  a  rare  condition,  and  is  usually  secondary  to  spinal 
disease  or   pelvic  deformity.     To  a  certain  degree  it   afi'ords 


Ay()MALU:s  OF   rTF.niSE   DEVh'LorMhWT.  21»7 

('()iii|M'iisati()H  ;  hut,  as  a  rule,  il  i-  not  siiniciciil,  and  a  I'dla- 
lioii  (»r  t!i(j  .sicniin  occurs,  x)  that  the  iippci-  end  is  llirowii 
hacUNvard  and  downward  ( Fin'.  ILSj.  'I'lic  pelvic  canal  tends 
to  become  t'niniel-sliaped  on  accoinit  of  tlie  projection  lorward 
ol'  tlie  l.»\vc'r  |)art  <»('  the  sacrum  and  the  partial  ohliteration  of 
the  piH)mont«»iT. 

At  the  iii/<(  th(!  conjiinate  is  increased  while  tiic^  antero- 
posterior diameter  is  dimini-hed.  The  diameters  at  the  oiifdf 
are  usually   more  or  less  diminished. 

Scoliosis:  'I'heett'ect  oi' scoliosis  on  the  pelvis  depends  on  tlie 
-iluation  and  extent  of  the  spinal  curvature.  'J'he  lower  it  is 
and  the  earlier  it  occurs,  the  more  serious  are  the  efllects  pro- 
duced in  the  ])elvis.  There  is  usually  some  deoroe  of  oMicpu; 
contraction  present  in  the  pelvis  of  a  j>atient  the  subject  of 
.■scoliosis.     'J'he  condition  is  fre<piently  associated  with   rachitis. 

Tlie  iniioiiihiatr  hdiic,  toward  which  the  lumbar  vertebrie  are 
<•  irve<i,  receives  the  greater  ])art  of  the  body-wei<:;ht,  and  is 
therefore  pushed  upward,  inward,  and  backward  by  the  extra 
pressure  exerted  on  it  by  the  head  of  the  i'euuir.  The  acctuhti- 
Inia  on  this  side  is  displaced  upward  and  inward  toward  the 
sacriun.  The  sj/))ij>}ii/.^it<  is  thus  pushed  toward  the  oj)posit<' 
side.  Thus  the  ijreatest  degree  oi'  pelvic  contraction  is  on  the 
side  of  flic  spi)ia/  ronrexifi/. 

In  (ahor  the  largest  part  of  the  head  generally  descends  on 
the  roomier  side  of  the  pelvis,  through  which  it  may  pass 
when  in  a  state  of  ijood   Hexion. 

In  cases  in  which  the  pelvic  deformity  is  extreme  the  Csesa- 
rean  operation  nuist  be  resorted  to. 

Kyphoscoliosis:  Rachitis  may  j^roduce  both  kyphosis  and 
scoliosis  in  tlie  same  woman.  If  the  kyphosis  is  situated  high 
up,  but  little  effect  may  be  produced  on  the  pelvis. 

3.  ANOMALIES  OF  THE  MATERNAL  SOFT  STRUCTURES. 

Anomalies  of  Uterine  Development. 

Varieties:  Tiabor  may  be  complicated  in  many  ways  in  a 
jiaticnt  who  has  a  double  or  se])tate  uterus.  ]Mal))ositions  of 
the  ffrtus  are  common.  The  unimj)regnated  half  may  caus(! 
obstruction  by  its  bidk,  as  it  usually  imdergoes  considerable 


it/ 


298  PATHOLOGY  OF  LABOR. 

increase  in  size  in  sympathy  witli  tl:'j  impregnated  iialf.     ]i 
tiie  placenta  is  attaclied  to  the  sejHum,  severe  hem()iTlia}:;e  ni;i\ 
take  j>lace  owing  to  imperfect    (;ontractiou.     Kupture  of  tlie 
septum  or  of  tlie  uterus  may  occur. 

The  decidual  membrane  which  has  formed  in  the  imjiroo- 
nated  half  of  the  uterus  may  be  retained,  and,  undergoing  pio- 
liferation  after  delivery,  may  give  rise  to  scj)tic  infection. 

In  all  cases  of  anomalous  development  of  the  uterus  labor- 
pains  are  usually  short  and  inefficient. 

Pregnancy  in  a  rudimentary  horn  is  a  most  dangerous  coiidi- 
tiou,  and  when  diagnosed  it  should  be  treated  as  a  case  oi 
ectopic  gestation. 

Treatment:  Forcej)s  or  version  must  be  resorted  to  in  nid-l 
of  these  cases  in  order  to  efleci  delivery.  The  former  shoiiM 
be  chosen  in  })reference  lo  the  latter  when  possible.  Cesarean 
section  may  be  necessary. 

Abnormal  Conditions  of  the  Cervix. 

Varieties :  Atresia,  cicatricial  conditions,  contraction,  aiul 
rigidity  of  the  cervix,  may  all  give  rise  to  more  or  less  ob- 
struction in  the  first  stage  of  labor. 

Atresia  is  a  very  rare  condition,  and  it  is  very  seldom  com- 
plete. The  situation  of  the  external  os  may  be  recogni/cd  :!,- 
a  dimple.  Pressure  upon  this  with  a  blunt  instrument,  sikIi 
as  the  tip  of  a  uterine  sound,  is  usually  all  that  is  rcqniicd  to 
perforate  it,  after  which  dilatation  usually  jiroceeds  raj)idly. 

Cicatricial  contraction  of  the  cervix  is  usually  due  to  old 
laceration,  or  it  may  arise  from  a  repair  operation,  from  cautir- 
ization,  or  from  syphilis  or  cancer. 

Rigidity  of  the  Cervix. 

Etiology :  When  not  due  to  orgnnic  chariffes,  it  is  said  to  be 
funcfio)ifil.  Functional  rigidity  is  common  in  highly  sensitive 
young  women  and  in  elderly  primiparre.  It  is  usually  due  to 
some  imperfection  in  the  nerve-supply  of  the  uterus,  and  i> 
frequently  associated  with  inefficient  uterine  contractions. 

Treatment:  When  tiie  rigidity  of  the  cervix  is  function..!  in 
origin  it  may  usually  be  overcome  by  the  employment  of  ncivo 


DISPLACEMENTS  OF  THE   IJTERf'S.  29{» 

sedatives  and  hot  douchos.  Syr.  chloral,  hydrat.,  siss,  should 
he  administered  in  warm  milk.  Ten  minutes  later  a  hot  vajr- 
inal  douche  (110°  F.)  should  be  «riven,  at  least  two  (juarts  of 
water  being  used.  Every  succeeding  ten  minutes  a  dose  of 
chloral  and  a  hot  douche  should  be  given  in  alternation,  till 
the  patient  has  received  three  doses  of  cidoral  and  three  hot 
douches,  should  the  cervix  not  yield  befui'e.  In  the  autiiors 
ex})erience  this  plan  of  ti'eatment  has  rarely  failed. 

In  some  eases  a  hypodermic  injection  of  mor{)hine,  gr.  ],  is 
all  that  is  required.  Painting  the  cervix  with  a  2  per  cent, 
solution  of  cocaine  has  been  hi<;hlv  recommended,  (k'casion- 
;dly  a  few  whiffs  of  chloroform  with  each  pain  act  like  a  charm 
in  relievino;  this  condition  when  it  occurs  in  a  hiirhlv  nervous 
patient. 

When  these  methods  fail,  artificial  dilatation  by  means  of 
the  fingers  or  by  the  introduction  of  a  Barnes  or  Cham[)etier 
(le  Ribes  bag  may  be  necessary. 

In  extreme  cases  it  mav  be  necessarv  to  make  several  small 
incisions,  one-quarter  to  oui'-half  inch  deep,  in  the  cervix  be- 
fore proceeding  to  artificial  delivery. 

Impaction  of  the  Anterior  Lip  of  the  Cervix. 

Occurrence:  This  condition  may  occasionally  obstruct  the 
advance  of  the  head  at  the  outlet.  The  anterior  lip  in  these 
cases  is  caught  between  the  head  and  })ul)es,  and,  becoming 
swollen  and  cedematous,  may  actually  protrude  at  the  vulva. 
After  labor  it  mav  slou";h. 

The  proper  treatment  is  to  attempt  to  j)ush  it  uj)  in  the 
intervals  between  the  pains.  If  it  be  v(My  (edematous,  it  mav 
l»e  necessary  first  to  make  a  number  of  small  incisions  into  it 
to  permit  the  escape  of  serum,  when  its  reduction  may  be  ac- 
complished without  difficulty. 

Displacements  of  the  Uterus. 

Anterior  displacement  of  the  uterus  at  the  time  of  labor  is 
not  infrequent.  It  is  generally  due  to  a  lax  C(»ndition  of  the 
abdominal  walls. 

Treatment  consists  in  the  application  of  a  tight  abdominal 


:]{)() 


pATiroLoay  of  labor. 


hinder,  and  in  k(.'('j)ii)<r  the  patient  on  lier  l)a('k  in  a  lialf-reclin. 
in<:;  posture  diirin<r  labor. 

Lateral  displacement  to  one  or  other  side  may  tal<e  pliu  i . 
The  pregnant  uterus  is  usually  tilted  slightly  to  the  right  sidi . 
VVhen  the  lateral  inclination  is  excessive  part  of  the  propuIsi\  • 
toree  of  the  uterus  is  lost,  on  account  of  the  pressure  of  tlif 
presenting  ])art  against  the  lateral  wall  of  the  pelvis. 

Treatment:  Lateral  displacement  of  the  uterus  may  Ix' cor- 
rected by  making  the  patient  lie  on  the  side  o])posite  to  that  lo 
which  the  fundus  is  directed. 

Retrodisplacement  of  the  gravid  uterus  lias  already  been  i< - 
ferred  to.  Should  the  case  go  on  to  full  term  the  distention  ot" 
the  uterus  to  accommodate  the  f<etus  is  accomplished  by  the 
stretching  of  the  anterior  wall,  while  the  fundus  and  the  jxi— 
terior  wall  remain  within  the  pelvis.  The  condition  is  knttwii 
as  "  posterior  sacculation  "  of  the  uterus. 

In  these  cases  the  cervix  is  always  displaced  anteriorly  and 
iy  j)ressed  close  to  the  abdominal  wall. 

Treatment:  Ciesarean  section  is  seldom  necessary  in  these 
cases,  as  delivery  can  usually  be  effected  by  artificial  dilatation 
of  the  cervical  canal  and  sul)se(]ueut  internal  version. 

Prolapse  of  the  pregnant  uterus  is  possible,  but  these  cases 
never  go  to  fidl  term.  The  prolapse  of  the  uterus  at  term  is 
usually  partial,  and  only  the  elongated  cervix  escapes  from  the 
vulva,  the  fiuidus  being  in  its  usual  ])osition  (Fig.  119).  In 
labor  the  cervix  may  be  retracted  within  the  vagina;  or  if  it 
be  rigi<l  it  may  become  oedematous,  and  by  its  bulk  prevent 
delivery  of  the  child. 

Trenfmenf :  AVhen  ])ossible  the  cervix  shoidd  be  pushed  into 
the  vagina,  and  retained  there  till  dilatation  occurs,  when 
forceps  may  be  ap])lied  and  the  child  delivtn'cd.  When  the 
cervix  is  rigid  and  oedematous  it  shoidd  be  freely  incised  and 
dilated,  to  permit  the  application  of  forceps  to  the  child's 
head.  An  assistant  may  coimteract  the  traction  of  the  forcoj)s, 
by  pushing  up  the  cervical  tissues  during  the  extraction  of 
the  child. ' 

Ventrofixation  or  suspensio  uteri  may  lead  to  obstruction  in 
labor  if  the  fundus  lias  been  attached  too  low  down  on  the  an- 
terior wall.  If  the  fundus  is  so  firmly  attached  to  flic  alxloin- 
inal  wall  that  it  is  prevented  from  rising,  the  anterior  wall  of 


DISPLACI'JMENTS  OF  Till-:   UTKRUS. 


301 


the  uterus  rcnuiius  crowded  down  over  the  pelvic  inlet,  while 
the  posterior  is  distended  and  <j:;reatly  thinned. 


Via.  119. 


Elongated  cervix  with  procidentia  durinf;  labor.     (I'.arnes.) 


The  complicationfi  of  labor  which  have  been  recorded  in  such 
cases  are:  inertia  uteri,  transverse  position  of  the  child,  dis- 
placements of  the  head,  cervical  ria'idity,  rnj)tin'e  of  the  uterus, 
ami  severe  lieniorrha<re  durinoi;  the  third  stnp:e  of  labor. 


302 


PATIIOLOaY  OF  LABOR. 


Traitment:  It'  tlie  obstruction  otf'ered  by  the  folded  aii<; 
tliickeiicd  anterior  uterine  wall  be  so  great  as  completely  to  en 
off  the  pelvic  inlet,  Ciusareau  section  must  be  performed.  1  i 
some  cases  it  may  be  possible  to  deliver  the  child  by  means  (>; 
version,  the  danger  of  this  operation  being  rupture  of  tli* 
thinned-out  posterior  wall  of  the  uterus.  The  writer  in  oiif 
case  was  able  to  push  the  anterior  wall  out  of  the  way  siii- 
ficiently  to  permit  tin;  application  of  the  forceps  to  the  head, 
which  was  then  drawn  down. 


Abnormal  Conditions  of  the  Vagina  and  Vulva. 

Longitudinal  and  transverse  septa  may  be  present  in  tin' 
vagina  and  obstruct  the  advance  of  the  presenting  part  of  the 
fetus.  They  are  seldom  very  dense  in  structure  and  are  ea-ilv 
ruptured.  If  they  do  not  yield,  they  may  be  divided  between 
ligatures. 

Unruptured  hymen :  This  conditi(Hi  may  be  found  present  in 
labor;  it  causes  but  slight  obstruction;  occasionally  it  may  he 
necessary  to  incise  it. 

Atresia  of  the  vagina:  Narrowing  of  the  vagina  mav  ho 
due  to  maldevclopment  or  to  cicatricial  contractions  after  ])n- 
vious  injury. 

Trcdtitiod:  Hot  douches  followed  by  injections  of  sterili/cd 
sweet  oil  may  be  employed  to  soften  the  part.  Dilatation  may 
be  eflfected  by  the  use  of  Champetier  de  Ribes's  bag. 

Rigidity  of  perineum:  The  perineum  mav  be  so  rigid  as  to 
prevent  advance  of  the  fetus.  This  condition  is  common  iii 
muscular  women  and  in  elderly  priniipar«3. 

Ti'catmoit :  In  these  cases  the  forceps  maybe  recpiired  to 
draw  down  the  fetus.  During  delivery  the  perineum  may  lie 
softened  by  the  free  use  of  hot  fomentations,  care  being  takin 
to  smear  the  parts  with  vaseline,  to  prevent  burning.  Wlun 
laceration  is  certain,  episiotomy  may  be  performed. 

Hsematoma :  This  condition  is,  when  present,  found  at  flu' 
vaginal  orifice. 

Treatment:  If  large  enough  to  obstruct  labor,  the  tumor 
should  be  excised  and  the  contents  cleared  out ;  after  delivery, 
if  hemorrhage  from  the  cavity  takes  place,  it  should  be  packed 
with  iodoform  gauze. 


TUMORS  OF  THE  GENITAL   CANAL,   ETC.  303 

Varicose  veins  wlien  prosent  seldom  (»l)stru('t  labor.  They 
iiiiiy  rupture  or  bo  so  bruised  i;s  to  slouijh  alterward. 

CEdema  of  the  vulva  due  to  heart  or  kiduev  disease  uiav  ob- 
struct  labor.  Multinle  puuetures  shoidd  only  be  resorted  to  in 
extreme  cases,  as  there  is  great  risk  of  sepsis  or  gangrene  fol- 
lowing delivery. 

Abnermal  Conditions  of  the  Bladder. 

Distended  bladder:  This  is  a  not  un(!ommon  cause  of  delay 
in  labor,  and  should  always  be  borne  in  mind.  The  urine 
.-hould  be  removed  with  a  sterile,  long,  soft  catheter,  the  pre- 
senting part  being  pushed  up  so  as  to  j)ermit  access  to  the 
1 -ladder.  In  cases  in  which  it  is  impossible  to  pass  the  cathe- 
t(  r  perforation  through  the  abdominal  wall  may  be  re(iuired. 

Cystocele :  In  this  condition  the  bladder  may  j)rotrude 
through  the  vulva. 

Treatiiif)d :  The  urine  must  be  drawn  by  means  of  a  soft 
(Mtlieter,  and  the  prolapsed  jxirt  afterward  pushed  gently  up 
:il)ove  the  presenting  part  of  the  fcetus.  If  reduction  prove 
imj)ossible,  the  part  must  be  held  up  while  the  child  is  ex- 
trncted  by  means  of  the  forceps. 

Vesical  calculus :  If  small,  the  calculus  may  not  obstruct 
labor.  If  possible,  it  should  be  pushed  up  above  the  sym- 
physis. 

When  large,  it  may  be  extracted  after  dilating  the  ure- 
thra; or  it  may  be  necessary  to  incise  the  bladder  through  the 
anterior  vaginal  wall.  After  labor  the  incision  may  be 
sutured. 

Tumors  of  the  Genital  Canal  and  Neighboring  Organs. 

Carcinoma  of  the  cervix :  It  may  be  said  that,  as  a  rule, 
when  this  condition  is  present  at  full  term  serious  obstruction 
to  labor  results.  Spontaneous  delivery  may  occur  if  the  dis- 
ca-o  is  limited  to  the  anterior  lip  and  is  not  surrounded  by  a 
large  area  of  cicatricial  infiltration. 

Hemorrhage  and  sepsis  are  likely  to  arise  during  the  puer- 
pcrium. 

( ^jesarean  section  is  the  proper  treatment,  if  the  disease  is 
fairly  extensive. 


304 


PATllOLOdY  OF  LAIiOR. 


Fibromyomata. 


Tlu'obstriu'tiors  to  hibor  rosiiltiiiLj  from  tlio  pmsciice  of'lil)i..- 
myomata  dciKiid  on  tljo  situation  of  tlie  new  <:;ro\vtli.  If  it 
s{)rin<r,s  from  tlic  lower  uterine  seamen  or  cervix,  it  nmv 
become  ineareei  ted  in  tlie  ])elvi«  and  absolutely  prevent  th  ■ 
descent  of  the  child  (Fig.  120). 


Fig.  lt>0. 


^fc'/i'/r> 


Per/neum 


Myoma  uteri  complicating  pregnancy.    (After  Spiegclberg.) 


Effects:  They  lead  to  mal presentations  and  malpositions  (d' 
the  f(etus,  to  prola})se  of  the  cord,  to  adherent  placenta,  and  in 
hcmorrha2:e.  The  lal)or-pains  are  likely  to  be  inefficient.  A 
tetanic  condition  of  the  uterus  is  not  infrequently  met  with  in 
these  cases. 

The  pressure  of  the  tumor  may  j)roduce  severe  contusions 
oi'  fractures  of  the  f<etal  skull.  The  tumor  may  be  so  injiiicil 
duriuii;  labor  that  sloughing  and  gangrene  may  follow  and 
give  rise  to  septic  infection. 


TUMORS   or   Till-:  O  lis  IT  A  L   CANAL,   ETC.  305 

Wlien  tli(!  tumor  is  sitiiiitcd  on  tlic  atitorior  wall  it  may  In' 
ijisplaccd  iij)\var(l  by  iit'-'riiie  coiilrjiclion,  and  thus  ceasu  to 
(il)stru('t  tlu'  advaii'-c  of  (he  child. 

Diagnosis:  When  situated  low  down  in  the  uterus  a  lihroid 
tumor  mav  l)o  mistaken  I'or  the  tu'tal  head.  A  careful  exami- 
nation should  jn-event  this  mistake. 

Prognosis:  This  de[)ends  upon  the  early  recojrnition  of  the 
condition  and  the  treatment  ad:){)ted.  'I'he  experiiMiee  of  the 
writer  leads  him  to  consider  the  presenei'  of  myoma  a  urave 
complication  of  labor.  In  a  series  of  300  of  tliese  eases  col- 
lected by  Lallcur  the  mortality  for  the  mothers,  of  delivery  by 
die  natural  passage,  was  25  to  55  })er  cent,  and  77  per  e(,'nt. 
I'or  tile  children. 

Treatment:  When  the  tumor  or  tujnoi's  are  HHimtcd  lti(/lt  up 
labor  mav  terminate  naturallv.  In  sonw;  eases  labor  is  pro- 
lono;('d  on  aeeount  of  uterine  inertia,  and  must  be  tei'minated 
liv  version  or   tbrceps. 

\\'hcn  the  fiiiDor  is  snia/f  and  situated  foir  doini,  it  may  be 
]ii>-siblc!  to  push  it  u|)0ut  of  harm's  way  by  placint]^  the  patient 
ill  tli(!  knee-chest  [)osition.  If  this  fails,  it  may  be  possible  to 
extract  the  child  by  means  of  the  tbrcej)s  with  the  woman  in 
W'alcher's  position.  If  this  be  impossible,  C^iesarcnui  section 
imist  be  performed,  or  else   Porro's  operation. 

if  the  tumor  is  suh)imi'nus  and  attached  to  the  cervix,  it 
may  be  possible  to  remove  it  by  enucl(>ation  evcMi  after  labor 
lia^  begun.  After  labor  the  tumor  cavity  .  hould  be  packed 
with  iodoform  gauze. 

In  all  caseti  iu  which  delivery  takes  place  through  the  natu- 
ral ])assagos  there  is  great  (hiuf/rr  of  Jirmorrliar/c  from  imper- 
fect contraction  of  the  j)lacental  site.  Should  hot  intra-uterine 
douches  and  iiypodermics  of  ergot  fail  to  control  the  hemor- 
rhage, the  cavity  of  the  uterus  must  be  packed  with  sterilized 
iodoform  j>;auze.  The  ijauze  mav  l)e  left  in  the  cavitv  for  three 
or  four  days,  and  if  necessary  it  may  then  be  renewed. 

Polypi. 

Mucous  polyps  usually  spring  from  the  cervical  canal  or 
anterior  lip  of  the  cervix,  and   wlien  present  may  obstruct 

labor. 

20— Obst. 


l){)6  PATIIOLOdY  OF  LABOR. 

Even  if  small,  these  polyj)i  sliould  be  removed  at  the  tini' 
of  labor,  by  transfixing  and  tying  the  palicle,  and  cutting 
them  away. 

Ovarian  Cysts. 

These  rarely  complicate  labor.  \i'  discovered  diiriiig  ])'(•-- 
nancy,  they  should  be  removed.  Small  ovarian  tumors  m:i\ 
prolapse  and  cause  obstruction  in  the  pelvis. 

Treatment:  If  the  tumor  be  foimd  below  the  brim  at  liir 
time  oC  labor,  efforts  should  be  made  to  push  it  u[)  into  liif 
abdominal  cavitv.  To  do  this  it  mav  be  necessaiv  to  :iii;i-- 
thetize  the  patient  and  to  place  her  in  the  knee-ehest  po>iti<»ii. 
If  it  be  impossible  to  re<luce  the  tumor,  it  may  be  tapped  Irmii 
the  vagina.  This  operation  cannot  be  recommende<l,  a^  ii 
exposes  the  patient  to  the  danjier  of  peritonitis,  from  e>ea|ic  of 
the  contents  into  the  peritoneal  cavity.  It  is  better  to  ju'ilo! m 
Csesarean  section,  and  at  the  same  time  remove  tiie  tumor,  h 
the  cyst  only  partially  occludes  the  j)elvic  inlet,  it  may  be  |h)-- 
sible  to  effect  delivery  by  version  or  forceps. 

Vaginal  cysts,  dermoid  cysts,  swellings  of  the  tubes  jiikI 
broad  ligaments,  prolapse  of  a  floating  kidney  to  the  jteK  Ic 
inlet,  hydatid  cysts  of  the  pelvis,  and  tumors  of  the  liver  ur 
spleen  may  be  found  to  cause  obstruction  in  labor. 

Rupture  of  the  Uterus. 

Occurrence:  Rupture  of  the  uterus  may  take  place  dnrinir 
pregnancy,  labor,  or  the  puerperal  period.  In  the  vast  major- 
ity of  these  cases  the  rupture  takes  place  during  the  seccpinl 
stage  of  labor,  and  consists  of  a  laceration  of  some  ])ortioii  ot' 
the  uterine  wall. 

Frequency:  This  accident  is  said  to  occur  about  once  in 
4000  cases,  but  the  writer  is  of  the  opinion  that  it  ociins 
much  more  frequently  than  is  generally  thought,  as  ])ra<- 
titioners  are  not  prone  to  report  these  cases  M'hen  they  occiii'  in 
private  practice. 

Etiology:  The  most  frequent  cause  of  rupture  of  the  uiriiis 
is  overdistention  of  the  lower  uterine  segment,  the  result  of 
some  obstruction  which  prevents  the  descent  of  the  present iiiir 
part  of  the  child. 


RUPTuiii:  or  Tin-:  uterus. 


307 


Thus  pelvic  (leformity,  overgrowth  of  the  cliild,  liydro- 
cepluiliis,  a  tumor  llockiiifj^  tlie  pelvis,  rii^idity  of  the  soft 
))art.s,  or  malpre.scntations,  result  in  eontraetions  of  tiie  uterus 
lureini^  the  child's  body  iiUo  the  \o\\vv  uterine  setiinent,  wiiich 
liei'onies  enormously  distended,  while  the  upper  sconicnl,  with 
its  walls  (greatly  thickened,  is  drawn  up  until  it  forms  a  dis- 
linet  t(i(nor,  wliieii  can  be  felt  throuj;h  tiie  abdominal  wall 
;i1m)V(>  the  child. 

There  is  n>uaily  a  irrU-dcfliud  line  between  the  thickened 
ii|)jter  segment  and  th<,'  distended  lower  segmeiif.  This  line  is 
Livnurally  visible,  as  well  as  palpable,  running  ()bli(|nely  across 
the  abdomen  somewhat  below  the  unibilii'us.  U'liis  is  tlu; 
ivtraction-ring,  or  so-called  "contraction-ring  of  Jiandl." 
W  hen  the  limit  of  the  capacity  of  the  lower  uterine  wall  in 
siniching  and  thinning  is  reached  rn])ture  takes  ])la(  \ 

When  the  utvrhic  trail  Is  iraikoicd  from  any  cause,  such  as  a 
Mow  or  tall  during  j)regnancy,  fatty  or  other  d(\generatif)U,  or 
iVom  malignant  or  other  disease,  ruj)ture  may  take  place  early, 
( Acn  without  UHich  distention  of  the  lower  segment. 

I'^inally,  rnj)ture  may  occur  during  unskilful  (iflnuj)fs  at  ver- 
sion, the  high  a[)plieation  of  Ibrceps,  or  separation  of  an  adher- 
ent ])lacenta. 

Ikupture  of  the  uterus  has  been  reconled  as  lollowing  the 
(uliiilnisb'afion  of  cr(/ot  to  hasten  the  exj)ulsion  of  the  child, 
-hilly  has  collected  thirty-three  such  cases. 

Site  of  the  rupture:  The  tear  usually  begins  in  the  wall  of 
tiic  lower  uterine  seo;nient  and  runs  transversely,  ^\'hen  the 
rii|iture  is  spontaneous  it  usually  occurs  in  the  Literal  wall. 
^\  lien  due  to  traumatism  the  anterior  wall  is  usually  the  site 
111'  the  laceration. 

The  c.vtcnf  of  the  tear  varies  from  a  small  rent  limited  to  the 
niiiseular  coat  to  complete  penetration  into  the  abdominal 
cavity.  Usually  the  edges  of  the  wound  are  jagged  and  irreg- 
ulai',  and  infiltrated  with  blood. 

When  only  the  muscular  coat  is  torn,  the  peritoneal  covering 
of  the  uterus  may  be  stripped  off  for  a  considerable  distance 
hovond  the  tear,  the  sac  thus  formed  becoming  filled  with 
blood-clot. 

The  foetus  and  placenta  may  escape  into  the  peritoneal  cavity 


308 


PATIJOLoaV  OF  LABOR, 


wlit'M  the  rent  is  extensive,  and  the  iiitestiut's  may  prolapse  iiiln 
the  vjit^iiia. 

Symptoms:  Rupture  of  the  uterus  wlien  extensive  is  usn:illv 
actioinpanied  witii  alariMiii<^  syniploins.  Tlie  uterine  e()iitr;i<  - 
tioiis  iiavc  probably  been  vij^orous  lor  some  time,  and  tli^ 
woman's  snirerin<r  beeomes  extreme.  Complaint  is  usinlly 
made  of  eontinuous  and  severe  eramp-like  pain  in  the  Idwir 
j)art  of  the  abdomen. 

On  (f/j(l()iii.iii(it  exdiiiiiKitioa  the  utenjs  will  be  found  in  a 
state  of  almost  tetanic  contraetion  with  the  lower  seii'iiiciit 
jrreatly  distended.  The  retraction-rino-  may  be  pal|):ibli',  ur 
even  visible.  Suddenly  there  is  a  peculiar  sharp,  lancinaiiiii: 
pain,  the  woman  <^ives  a  loud  cry,  and  asserts  that  something 
has  torn.  Tiie  sound  of  the  tear  may  be  audible.  'riitn 
follows  absolute;  cessation  of  lUerine  action.  Blood  Hows  I'luiii 
the  Viiii'ina,  and  symptoms  ol'  profound  shock  i'a[)idly  (lev<lii|i. 

On  makinj^  a  Viujiiidl  exwuinatUm,  the  j)resentin<i'  [Kirt  wiil  lie 
found  to  have  receded  ;  a  loop  of  intestine  may  1k'  encount(  ivd, 
or  the  hand  may  pass  through  the  rent  into  the;  abdoiuinal 
cavity. 

When  the  rupture  is  only  |)artial,  there;  may  be  no  sym)ii(>iii>< 
until  after  the  birth  of  the  child.  There  may  be  a  moderately 
severe  hemorrhage  before  the  placenta  comes  tiway.  Utciinc 
action  is  usually  poor,  and  there  may  be  <ome  dilficulty  in  ex- 
pelling the  ])lacenta.  Tlu;  uterus  tends  to  remain  flaccid,  and 
there  may  be  some  |)Ost-))artum  hemorrhage.  None  of  tln^c 
symptoms  may  suggest  the  condition  actually  present.  TIn' 
ra})id  development  of  sej)tic  peritonitis  may  lead  to  an  iiitia- 
uterine  examination  being  made  within  twenty-four  or  t'oiiy- 
eight  hours,  when  a  partial  laceration  will  be  discovcnil  it' 
the  uterine  cavity  be  carefully  exi)lored. 

The  author  has  had  experience  of  one  case  in  which  tin  ic 
were  no  si/inptotns  to  indicate  that  rupture  had  taken  pLur, 
beyond  a  somewhat  severe  hemorrhage  with  the  expulsion  <<\' 
the  placenta.  On  the  second  day  of  the  |>uerperal  period  iIh' 
patient  developed  a  slight  temperature,  and  on  the  third  a 
severe  hemorrhage  took  place.  On  making  an  intra-nlciini' 
examination  a  rent,  sufficiently  large  to  admit  two  fingoi-  \\a« 
found  in  the  posterolateral  wall  just  above  the  external  <>-. 

The  prognosis  depends  on  the  site  and  extent  of  the  laci  la- 


nrVTL'llE  OF  THE   riEiius. 


3li!> 


lion  as  well  as  upon  tlic  treatment.  The  maternal  mortality 
under  the  host  treatment  runs  as  liij^h  as  (10  per  cent.,  while 
ihe  mortality  of  the  infants  is  as  hitjh  as  OO  per  cent. 

Complete  rnptnre  is  nmeh  more  liUely  to  j)rove  fatal  than  is 
pai'tial  I'nptiii'e,  on  aeeonr.t  of  the  involvement  of  (he  peritoneal 
.;i\itv.  Moi'e  than  one-haif  of  the  cases  perish  within  Uventv- 
I'uur  lionrs  of  the  ae<'i(lent.  The  causes  of  death  ari'  .sepsis, 
licmori'hai;'e,  an<l   >hoel\'. 

Treatment:  When  vi>i;orons  uterine  contractions  fail  to  <'an>c 
;id\ance  of  the  pi'e.-entinu-  j)art,  the  condition  of  the;  lower 
iiiei'ine  segment  should  Ih'  a->eerlained.  When  the  retraction- 
riiii;  of  IJandl  is  to  he  felt  half-way  hetween  the  jxihes  and  tlu! 
iinihilicus  lahor  should  be  terminated  as  rapitily  as  posslMe,  in 
older  t(»  ^uard  ai;ainst  the  occuri'ence  of  rupture.  Tlu^  pro- 
(cdurc  to  he  adoj)ted  will  depend  on  the  conditions  [)re>enl. 
r.clore  (»peratin_!j;  the  patient  should  he  antestheti/e<l  t(>  the 
-iH'Liical  de<i;ree,  and  if  this  fails  to  relax  the  uterus  cinnpletely 
a  liy|)odormic  injection  of  morphine  may  he  ^iven. 

What  rKjifnrc.  h<is  tnhcii  jt/acc  the  physician's  first  duty  i.s  to 
( iii[)ty  the  uterus  and  to  control  hemoi*i'haui:e.  If  the  child  has 
ii.it  escape(l  into  th(;  peritoneal  cavity,  it  shoidd  he  delivered 
r;i|)idly  hy  the  apj»licati<tn  of  foi'ceps  or  hy  craniotomy.  Tlu; 
lilacenta  shoidd  then  he  removed  maiuially,  and  the  site  and 
extent  of  the  laceration  examined. 

In  bu'omph'ie  htccrdiion  it  is  sulHcient  to  irri<>;ato  the  cavity 
(if  th(!  rent  with  a  hot  antiseptic  solution,  such  as  formalin 
(1  : -jOO),  and  to  pack  it  gently  with  iodoform  gauze.  This 
tivatment  shoidd  be  repeated  at  intervals  of  from  twenty-four 
to  forty-eight  hours  until  the  rent  has  healed. 

When  the  rupture  is  found  to  be  ('o)npl(if  the  treatment 
(It  pends  on  its  site  and  extent.  WIh.'u  it  is  small  and  situated 
ln\v  down,  and  but  little  if  any  I'oreign  mattei*  has  escaped  into 
llir  pei'itoneal  cavity,  the  rent  may  be  irrigate*!  and  j)acl<ed 
with  iodoform  gauze.  In  such  a  case  a  close  watch  should  be 
k(j)t  for  symptoms  of  ]>eritouitis  ;  and  if  such  develop  the  abdo- 
111(11  should  be  promj)tly  opened,  the  ])eritoneal  cavity  cleansed. 
Mild  tliorough  vaginal  and  abdominal  drainage  provided. 

When  the  rupture  is  (wfcnsit'c  the  abdomen  should  be 
l)r(»mptly  opened  and  the  peritoneum  cleansed  of  all  clots  and 
otlier  foreign  matter.     If  the  edges  of  the  wound  are  ragged 


all)  PATIIOLOUY  OF  LABOR. 

iiiid  inlillrated  with  hlood,  no  sutures  will  hold  ;  in  tlii-  ci c 
some  aiiliiors  rccomniciKl  that  tho  uIci'Uh  be  removed,  wiiilr 
oliiers  claiii.  rxcellriit  results  [hnn  merely  jjrovidiug  lor  «;(iii,| 
va<j:iiial  aixl  aiidoiiiinal  di'aiiiaLre. 

The  eoiiditioii  oi' s/iarl:,  iC  present,  siioidd  he  treated  hv  siillii. 
iiijeetioii,  stryeluiiiie,  di<;italis,  and  hraiidy,  and  the  aj)|ili('atinii 
of  heat  to  tiie  >urfaee  of  the  body. 

In  th(!  author's  exj>eiieuee,  limited  to  four  eases  in  wliiii 
treatment  \vas  j)()ssil)le,  most  excellent  re.>tdts  followed  cart  In  I 
irrijijatiou  and  ^auz(!  paddnj;'.  In  two  of  these  eases  tin;  jn  r- 
forations,  though  small,  extended  e(»mpletely  hron^h  liic 
uterus.  The  hemorrhage  was  severe  in  all  f)  'i  eases,  Im 
could  be  faii'ly  well  controlled  by  pressin<^  tiic  uierns  fu'inlv 
down  into  the  pelvis  iVoin  above. 

Al'ter  the  hot  douche  the  blood  ceases  to  flow  for  a  slmit 
periotl;  this  time  nuist  be  utilized  by  <|uiekly  j)ackinn-  the 
cavity  of  the  rent  with  ^au/e,  which  may  l)e  fz;uided  into  phi" 
aloui;  tlie  fin<;ers  of  the  left  hand  jdaeed  in  the  cervix. 

(ireat  care  nuist  be  exercised  in  removing  the  gauze  packing. 
when  this  is  necessary  ;  it  must  be  drawn  out  bit  by  bit,  slowlv 
and  ge.itly,  in  order  to  avoid  start iuii'  Ji  hemorrhage.  The  nn.-i 
rigid  asej)sis  is  recpiired  in  the  j)erformance  of  each  dressing  n\' 
the  laceration.  'J'he  gauze  ])acking  should  not  be  too  linn, 
though  sufficient  should  be  inserted  to  prevent  bleeding,  I  mi 
not  so  tightly  packed  .'is  to  prevent  free  drainage. 

Inversion  of  the  Uterus. 

Occurrence  :  This  accident  is  fortunate! v  extremelv  rare.  It 
is  met  with  more  frequently  in  pilvate  than  in  hospital  j)i;i(- 
tice.  Inversion  of  tho  uterus  may  be  acute  or  clirooic.  Ii  i- 
wiili  the  acute  form  the  obstetrician  has  to  deal.  The  iii\'i- 
sion  may  be  jHinidf  or  compldc. 

In  partial  inversion  the  fundus  may  be  the  site  of  a  dip- 
shaped  depression,  or  it  may  actually  prolapse  sufficiently  to 
protrude  from  the  os. 

In  complete  inversion  the  uterus  is  turned  inside  out,  mid 
may  protrude  from  Uie  vulva,  appearing  as  a  rour  led  ni;i>s 
between  the  ])atient's  thighs, 

Etiology :  Complete  inertia  uteri,  or  uterine  paralysis,  at  the 


iNVFiisioy  OF  Tin:  ("n':iiijs. 


:MI 


close  of  the  set'oiul  sta<i;t'  <il'  I;il)i»r,  is  tlic  mo>t  impoitnut  \)\v- 
(lisposiiii;  c'liiist'.  It  may  occur  spontaiu'dii-ly,  aiul  imnicdiatclv 
Inllnw  the  hirtli  of  the  cliiM. 

It  lias  boon  |)ro<hice(l  hy  im^kill'til  atlctnjtts  at  plactMital  ex- 
j)iil>ioii,  Tructinii  (HI  till'  cord,  to  aid  the  cx|uilsioii  of  tlie  |»l:i- 
ceiita,  has  brought  about  inversion.  When  thero  is  an  actiial 
or  rehitivo  .shorteninj^  of  the  cord  it  is  possibU'  that  the  trnc- 
tion  on  the  placental  site  njay  drag  down  the  I'nndns  so  as  nlii- 
niately  to  j)rodnce  inversion. 

Symptoms:  'J'he  inversion  nsnally  takes  place  siiddeidv,  and 
is  associated  with  sevci'e  shock,  pain,  and  heinorrhaiz,t'.  N'csical 
and  rectal  tcnesmns  may  be  present.  The  pain  is  usually  severe, 
while  the  hemorrhai:;e  is  rarely  proluse.  liy  abdominal  exam- 
ination the  absence  of  the  uterine  tinnor  will  be  noticed.  On 
inakinii;  an  internal  examination  the  inverted  I'nndns  will  be 
found  either  {)rotrudinj^  from  the  os(n'  pos-ibly  completely  till- 
ing;- the  vay-ina. 

Diagnosis:  Inversion  of  the  uterus  can  usually  be  diagnosed 
by  a  careful  external  and  internal  examination.  The  only  con- 
dition from  which  it  nuist  be  diiVerciUiated  is  i)rolapse  of  a 
uterine  polypus.  The  most  important  |)oint  in  (li:>tin<;uishin<!; 
Iietween  these  conditions  is  the  presence  oi*  absence  of  a  utei"ine 
cavity.  This  can  usually  be  demonstrated  or  excluded  satis- 
factorily by  the  introduction  of  a  uterine  sound. 

Prognosis:  In  the  acute  form  the  mortality-rate  is  extremely 
high.  Death  may  take  j)lace  in  a  few  hours  from  shock,  hem- 
(irrhage,  or  exhaustion,  or  later  trom  septicemia. 

RiH'ovcry  has  followed  spontaneous  reposition,  and  after  sep- 
aration of  the  inverted  organ  by  sloughing. 

Sponfancouii  irposifioii  is  more  likely  to  occur  when  the 
inversion  is  partial  than   when   it   is  complete. 

Treatment:  Reposition  bv  ftt.vis  is  the  onlv  treatment  usnallv 
Mvailable.  If  the  placenta  is  still  attached  to  the  uterus,  it 
should  be  separat(?d  before  re])osition  is  attempted.  The  uterus 
should  be  douched  with  a  hot  antiseptic  solution.  The  patient 
should  then  be  anaesthetized  and  placed  iu  the  lithotomy  posi- 
tion. The  body  of  the  uterus  should  be  gently  pushed  back 
within  the  vulva,  and  the  operator's  hand  inserted  into  the 
vugina  and  well  back  toward  the  sacrum,  having  the  palm 
'Hrected  up, ward.     The  finger-tips  then  grasp  the  lower  uterine 


312        PATJIOLOaV   OF  THE  PUERPERAL  PERIOD. 

sogniont  and  exert  pressiir*  i.^/on  it,  in  a  direction  upward  and 
forward,  toward  the  anterior  abdominal  wall,  and  in  the  axi-, 
of  the  pelvic  inlet. 

AJlvr  the  r<'i)Osiiio)i  has  been  completed  the  hand  should  Iw 
ke[)t  within  the  cavity  until  a  contraction  occurs,  when  it  m;iv 
be  trentlv  withdrawn.  A  hot  intravaj^inal  douche  should  then 
be  given,  and  strychnine  (<^r.  ■^^J)  cond)ined  with  ergotine  (gr. 
^\,)  administered  hvpodermically. 

It'etlbrts  at  immediate  reposition  fail,  it  should  beattempt-d 
a<rain  witiiin  a  few  hours. 

If  it  be  impossi!)le  to  reduce  the  inversion,  measures  should 
be  taken  to  prevent  the  occurrence  of  septic  infection,  and  dw 
case  left  for  operative  treatment  at  a  later  date.  If  infection 
occur,  the  best  method  is  vaginal  hysterectomy. 


PATHOLOGY  OF  THE  PUERPERAL  PERIOD. 
HEMORRHAQES   DURING   THE   PUERPERIUM. 

Post-partum  Hemorrhage. 

Definition :  Excessive  loss  of  blood  from  the  genital  canal 
immediately  following  the  birth  of  the  placenta,  or  taking 
place  within  twenty-four  hours  of  labor,  is  usually  termed  post- 
partum hemorrhage. 

Etiology :  The  connnonest  cause  of  this  grave  accident  is  mis- 
management of  the  third  stage  of  labor.  8j)iegelberg  h:i- 
stated  that  severe  post-partum  hemorrhage  is  almost  without 
exception  the  fault  of  the  medical  attendant.  It  is  certain  th:it 
this  accident  is  met  with  nnich  more  freciuently  in  ]>rivate piac- 
tice  than  in  well-organized  maternities,  the  reason  being  that  In 
these  institutions  the  attendants  are  individuals  of  sj)ecial  skill. 

Vte/inc  inertia  is  a  frequent  cause  of  post-j)artiun  hemor- 
rhage. The  uterus  fails  to  retract  properly  after  tlie  expulsion 
of  the  placenta;  hence  the  placental  sinuses  remain  patent,  ami 
blood  is  poured  out  into  the  uterine  cavity,  where  clots  form. 
which  acting  as  a  foreign  body  may  stimulate  contraction-. 
These  contractions  are  usually  weak  and  inefficient,  while  tin 
intra-utcriue  clots  are  more  or  less  firmly  attached  to  the  walls, 


POST- PA  R  TUM   U  KM  GURU  A  GE.  ?)  1 ;) 

and  licnoo  (lifHcult  to  dislodge.  In  tlio  intervals  between  tlie 
contractions  more  blood  is  poured  out,  nntil  liiiMlly  by  this  j)roc- 
ess  the  uterus  may  become  distended  to  its  lidl  capacity.  The 
external  hemorrhajie  mav  be  insi»inilicant  in  amount,  tliouirli  it 
is  usually  o;reatlv  in  excess  of  the  normal. 

Of/icf  coiKlHioiis  which  predispose  to  liemorrha<z;e  are :  pre- 
cipitate labor;  overdistention  of  the  uterus,  as  in  hydramnios, 
twin  pregnancy,  etc.;  adistinded  bladder  or  rectum  ;  the  reten- 
tion of  small  portions  of  the  placenta  or  membranes;  tumors 
and  other  new  growths  in  the  uterus;  and  exhaustion  following 
a  prolonged  and  tlilHcult  labor. 

CV'rtain  con^Cdxtional  c())\<lUinux  ))rodispose  to  this  accident, 
as  ne[)hritis,  extreme  aiuemia,  ;"U<1  luemophilia. 

Severe  post-partum  hemorrhage  \\\a\'  result  from  l((cn'<(li())i.s 
ill  the  lower  part  of  the  birth-canal.  Lacerations  of  tin;  cer- 
vix involving  the  circular  artery,  or  of  t!ie  vulva  involving 
one  of  the  bulbs  of  the  vestibule,  may  occasion  severe  hemor- 
liiage. 

Symptoms  :  The  liemorrhage  may  occiu*  with  or  after  the  ex- 
j)idsion  of  the  placenta.  It  may  be  an  abrupt,  sharp  hemor- 
rhage, or  simply  steady  dribbling  which  by  its  persistence 
results  in  an  extensive  loss  of  blood.  The  l)leeding  may  be 
external,  internal,  or  both. 

The  pulse  is  the  most  certain  indicator  of  the  severity  of  the 
hemorrhage.  If  after  delivery  the  pulse-rate  shows  a  tendency 
to  become  more  raj)id,  the  possibility  of  hemorrhage  must  be 
borne  in  mind.  It  is  a  good  rule  not  to  leave  a  patient  whose 
piilse-rate  is  100  or  more  to  the  mimite  till  all  possibility  of 
the  occurrence  of  hemorrhage  has  ])assed. 

fn  a  sfirir  case  symptoms  indicative  of  extensive  blood-loss 
iapi<lly  develop.  'The  j)ulse  becomes  rapid  and  thready  ;  res- 
piration is  shallow,  rapid,  and  sighing;  the  |)atient  becomes 
restless  in  her  movements,  tossing  herself  about  and  calling  for 
air.  SwO  .nay  complain  of  thirst.  Her  skin  becomes  cold  and 
covered  with  a  clammy  sweat.  If  the  hemorrhage  continues, 
syncope,  convulsions,  and  death  bring  the  painful  scene  to  a  dose. 
The  diagnosis  is  seldom  difficidt,  though  in  conditions  of 
severe  shock  occurrini»:  immediatelv  after  labor  all  the  ss-inp- 
toms  of  severe  hemorrhage  may  be  present,  except  evident  loss 
of  blood  and  a  relaxed  uterus. 


311        PATIIOLOdY   OF  rilE  PUKRPEILAL   PERIOD. 

The  blanclu'd  fiico,  cliiminy  skin,  rapid,  thready  pulso,  and 
sij^hinjjj  respiration,  all  indicate  h(!niurriiaui:c ;  though  the  ex- 
ternal loss  of  i)h)o(l  may  have  l)een  out  of  all  j)ro[)ortion  to  tlic 
syinptonis  })resent.  On  palpation  of  the  ahdoinen  the  hard 
globular  uterus  will  he  missed  from  its  usual  location  half-\va\- 
between  the  umbilicus  and  symj)hysis,  and  the  soft,  boggy  fuiKJu^ 
nuiy  be  found  reaching  almost  up  to  the  ensiform  cartilage 

In  cases  in  which  tlie  hemorrhage  arises  from  lacerations  dC 
the  lower  jxu't  of  the  l)irth-canal  the  fundus  will  be  found  in 
its  usual  position,  firndy  conti'acted,  in  spite  of  the  fact  tli.ii 
l)lood  is  escajjing  from  the  vulva.  An  internal  examinatjo  i 
by  means  of  a  speculum,  if  necessary,  will  reveal  ihe  bleedii.- 
})oint. 

Prognosis:  These  cases  rarely  terminate  fatally  when  skillcil 
assistance  is  at  hand.  The  gi-eater  the  loss  of  blood  the  grave!' 
is  the  prognosis.  The  most  unfavorable  casor  '  -'  those  in 
which  the  blood  lo-t  is  thin  and  wate;*y,  an(.  lils  to  clot 
properly,  as  this  is  indicative  of  ;i  blood  dyserasia. 

Treatment  of  Post-partum  Hemorrhage. 

This  accident  can  usually  be  prevented  by  the  proper  man- 
agement of  the  third  stage  of  labor.     The  directions  <riv<Mi  for 
the  management  of  the  third  stage  of  labor  constitute  an  oni 
line  of  the  preventive  treatment  of  post-partum  hemorrhage. 

The  prompt,  energetic  treatment  of  a  case  of  post-partmu 
hemorrhage  calls  for  self-(!ontrol,  readiness  in  resource,  ami 
presence  of  mind  on  the  part  of  the  physician.  His  object  i- 
to  secure  good,  firm  contraction  of  the  uterus.  It  is  well  to 
have  clearly  in  mind  a  routine  treatment  to  secure  this  object. 

The  first  thing  to  be  done  is  to  stimulate  the  uterus  to  action 
by  making  vigorous  friction  over  the  fundus,  through  tli' 
abdominal  wall.  As  the  organ  becomes  outlined  on  contrm  i- 
ing,  pressure  may  be  exerted  in  the  manner  recommended  t"i 
the  expulsion  of  the  placenta.  Such  compression  may  lead  ii 
the  ex])ulsion  of  clots  from  the  genital  canal,  and  furtli' r 
hemorrhage  may  cease.  If  this  fortunate  result  does  not  follow, 
the  free  hand  should  be  inserted  into  the  vagina  and  j)as-i(l 
into  the  uterus,  and  adherent  clots  may  be  loosened  and  brol^n 
up  by  .scraping  the  walls  with  the  finger-tips.  The  utern- 
should  then  be  rubbed  and  kneaded  between  the  external  ami 


POST-PAR TUM  HKMOPdlllA UK.  W 1 5 

internal  hands,  so  as  to  stimulate  contractions.  As  soon  as 
contraction  has  been  secured  tiie  internal  hand  siuiild  he  with- 
(li'.iwn  and  an  intra-uterine  douche  of  hot  sterilized  water  sliould 
he  «:;iven.  To  be  etl'ectual,  the  water  shouhl  i)e  between  115° 
and  125°  F.,  and  at  least  a  uallon  should  b(,'  employed.  A 
fountain-douche  should  be  usetl,  and  the  nozzle,  either  of  u'lass 
or  metal,  should  be  carried  to  the  fundus,  ^\'ilile  the  douehe 
is  beini^  given  the  fundus  should  be  kneaded  throui;'li  the 
abdominal  wall. 

If  the  hemorrhage  is  not  checked  by  this  means,  the  injec- 
tion shoiilil  be  repeated,  after  adding  to  the  sterilized  water 
enough  acetic  acid  to  make  a  3  per  cent,  solution — /.  <■.,  four 
ounces  to  the  gallon.  If  this  fails  to  stop  the  bleeding,  then 
the  uterine  cavity  must  be  tamponed  with  strips  of  iodoform 
gauze. 

The  technique  of  this  procedure  is  very  simple.  The  ante- 
rior lij)  of  the  cervix  is  seized  with  a  tenaculum-foreeps  and 
drawn  down  to  the  vulva.  The  end  of  a  strip  of  gauze  is  theii 
seized  by  means  of  a  pair  of  uterine  dressing-ibreeps  and 
guided  to  the  fundus;  then  the  whole  cavity  is  firmly  packed 
with  successive  layers,  ft  is  not  necessary  to  ])aek  the  vay^ina 
:is  well,  but  after  removing  tlu^  tenaculum  from  the  cervix  a 
strip  of  gauze  may  be  ]>laced  in  tlu^  ujijier  ]>art  of  the  vagina 
to  keep  the  cervix  in  place.  The  gauze  may  be  left  in  ])lace 
from  twenty-four  to  forty-eight  hours  and  then  gently  removed. 
It  is  seldom  necessary  to  repeat  the  intra-uterine  packing. 

As  soon  as  the  uterus  has  been  emptied  of  clots  a  hypodei'- 
niic  of  ergot  (aseptic,  Parke,  Davis  (Vr  Co.),  .^ss,  should  be 
given,  and  repeated  in  half  an  hour  if  required.  \i'  aftc^r 
the  first  hot  douche  no  acetic  acid  is  available,  a  j)iece  of 
sterilized  gauze,  or  even  a  clean  pocket  handkerchief,  may  be 
saturated  with  vinegar,  carried  to  the  fundus,  and  there  s((ueezed 
out.  The  vinew-ar  should  be  strained  throtii>;h  cotton- wool 
before  being  used  for  this  purpose. 

Having  checked  the  hemorrhage,  the  physician's  duty  is 
then  to  combat  the  evil  effects  of  severe  loss  of  blood. 

Treatment  of  Acute  Amvinia. 

The  pillows  sliould  be  removed  from  beneath  the  patient's 
head  and  the  foot  of  the  bed  raised  on  some  books  t)r  bricks. 


316        PATHOLOGY  OF  THE  PUERPERAL  PERIOD. 

Hot-water  bottles  should  ho  applied  to  the  extremities  of  the 
patient,  and  s'lie  should  he  covered  with  warm   hlaukets.      It 
tliere   is  a   tendeiiev   to  syncope,  a   hypodermic    injection   of 
strychnine  nitrate  (or.  .^)  and  nitroglycerin  (gr.  yj,,)  should 
be  given. 

As  soon  as  possible  a  (piart  of  watei-  at  110°  F.,  containing: 
two  teaspoon t'n Is  of  c  )nunoii  salt,  should  he  injected  into  tin 
I'ectum.  For  this  purpose  a  soft-rubber  catheter  shonhl  1h 
attached  to  the  noz/lc  of  a  fountain-syringe,  so  that  the  injec- 
tion  may   be  carried   as  far   u\^  as  })ossible. 

\X  the  heart's  acition  fails  to  improve,  hypodermic  injections 
of  ether,  strychnin,  and  nitroglycerin  may  be  employed. 

Nausea  and  vomiting  are  frequent  in  these  cases,  and  there  is 
but  little  absorption  from  the  stomach  until  these  cease.  As 
soon  as  the  stomach  will  retain  anything,  small  (juantities  of 
hot  coffee,  hot  brandy  and  water,  or  warm  milk  may  be  gixcii 
and  frefpiently  repeated.  A\'hen  reaction  has  been  estabhshcd 
a  hypodermic  of  morphine  (gr.  \)  should  be  given  to  quiet  th(( 
patient. 

In  desperate  cases  the  saline  solution  may  be  sterilized,  and 
inj(M^ted  beneath  the  breasts  or  directly  into  the  median  ba>ili(' 
vein  : 

To  insert  the  salt  solution  beneath  the  breasts  a  large  ex- 
ploring-needle  may  be  used.  A  ghiss  funnel  and  a  ])iece  of 
rubber  tubing  com])lete  tiic  apj)aratus.  These  should  be  ster- 
ilized after  bein<r  fitted  toy-ether  for  use.  The  breasts  are  then 
washed  with  soaj)  and  hot  water,  and  rubbed  with  alcohol. 
Having  filled  the  finniel,  the  physician  grasj)s  the  breast  firmly 
with  one  liand,  lifts  it  from  the  chest-wall,  and  with  the  otlii  r 
hand  the  needle  (with  the  solution  flowing  from  it)  is  plimgcd 
i)oldly  into  tlie  loose  tissue  beneath  the  breast.  Care  should 
be  taken  to  prevent  the  entrance  of  air. 

Intravenous  injection  is  seldom  used  on  account  of  tiie  tiuu' 
re(|uired  to  perform  the  operation,  and  because  the  methods 
before  given  answer  tlie  purpose  just  as  well.  For  the  methcl 
of  ojieration  the  reader  is  referred  to  works  on  surgery. 

Convalescence  in  these  cases  is  slow  and  tedious.  The 
patient  should  not  be  allowed  to  sit  ui^'ight  for  two  or  three 
weeks.  The  diet  should  consist  largely  of  fluids,  and  iron  in 
some  form  should  be  administered. 


HEMATOMA.  317 

Puerperal  or  Secondary  Hemorrhage. 

Definition:  Tliis  term  is  iiswl  to  denote  lienioi-rhiiiic  tVoiu 
tlie  tienitul  canal  of  a  woman  oeeurrinuL-  at  anv  time  after  the 
Hrst  twenty-fonr  honrs  to  tlie  end  of  the  pnerperinm. 

Etiology:  Tlie  most  frequent  eanse  of  secondary  liemorrliajre 
during  the  pner[)erium  is  the  retention  of  })(»rtions  of  placenta 
and  membranes.  Clots  in  the  utei'ine  cavity  or  the  dislodiije- 
ment  of  clots  in  the  placental  site,  dis[)lacements  of  the  uteru-, 
relaxation  of  the  uterus,  fibroids,  polypi,  partial  rupture,  the 
separation  of  a  slough,  and  overdistention  of  the  bladder  or 
rectum  may  b(!  mentioned  as  giving  rise  to  puerperal  hemor- 
rhage. Sudden  emotion  or  constitutional  causes  may  result  in 
iiemorrhage  during  the  pnerperinm. 

Diagnosis:  Having  the  causes  in  mind,  it  is  the  duty  of  the 
j)hysician  to  make  a  careful  external  and  internal  examiuiition 
in  all  cases  of  secondaiy  hemonhage.  The  diagnosis  should 
rarely  prove  dilficult. 

The  treatment  dejx'uds  on  the  cause  of  the  hemorrluige. 
After  emptying  the;  bladder  the  cavity  of  the  uterus  should  be 
ex})loied.  Fragments  of  placenta  and  membi'anes  or  clots 
should  be  removed  and  a  hot  intra-uterine  douche  given.  If 
the  cause  is  found  to  be  other  th:in  those  just  mentioned,  ap- 
propriate treatment  should  be  inaugurated. 

Haematoma. 

Definition:  In  this  form  of  hemorrhage  the  effusion  of  blood 
is  interstitial.  The  result  of  this  accident  is  the  formntion  of 
a  tumor  varving  in  size  with  the  dcc-rce  of  the  hemorrhage. 
The  most  frequent  situation  of  luematoma  is  in  one  or  other 
labium,  rarely  in  both.  It  may  occur  in  any  portion  of  the 
genital  canal  outside  of  the  uterus. 

Etiology  :  A  varicose  and  congested  condition  of  the  pelvic 
veins  predispose  to  the  occurrence  of  this  accident.  The  de- 
termining cause  is  usually  direct  injury  of  the  tissues  from 
l)ressure  of  the  fcetal  head  or  from  forceps.  Forcing  or  strain- 
ing on  the  part  of  the  woman  may  lead  to  tlie  rupture  of  an 
engorged  vein,  and  so  give  rise  to  the  condition.  It  may  occur 
before  or  after  the  completion  of  labor. 


318        PATHOLOGY  OF  THE  PUERPERAL   PERIOD. 

Treatment:  If  possible,  the  absorption  of  the  eff'used  blood 
should  !)('  eii('oiir;»y:e(l.  Care  should  be  taken  to  avoid  it- 
manipulation  in  performing  the  toilet  of  the  vulva.  Frcqiiciii 
gentle  irrigation  with  warm,  mild  antiseptic  solutions  may  be 
employed.  If  absorption  is  delayed,  the  tumor  should  be  in- 
cised, the  contents  turned  out,  and  the  cavity  packed  with 
iodoform  gauze.  If  on  incising  the  tumor  a  bleeding  vessel  is 
found,  it  should  be  tied  before  pa( l.ing  the  cavity.  Frecjuciit 
dressing  and  rl^  'd  asepsis  are  necessary  to  prevnt  the  oeciu'- 
rence  of  infection. 

SUBINVOLUTION. 

Definition:  When  the  process  of  involution  of  the  puerperal 
uterus  is  arrested  or  retarded  the  organ  is  said  to  be  in  a  con- 
dition of  subinvolution. 

Etiology. 

Any  condition  which  prevents  a  rapid  diminufion  in  the  hlooil- 
tiJippli/  of  the  puerperal  uterus  may  be  said  to  be  a  cause  (»1 
subinvolution.     Any  condition  which   inicrferes  irith  contrw- 
tions  of  the  muscular  tissues  of  the  puerperal  uterus  tends  to 
give  rise  to  subinvolution. 

The  following  conditions  which  tend  to  interfere  with  the 
diminution  of  the  blood-supply  of  the  puerperal  uterus  may  be 
mentioned  as  giving  rise  to  subinvolution  :  hyperplasia  of  the 
endometritnn,  the  result  of  local  congestion  or  of  mild  se])ti(! 
infection;  laceration  of  the  cervix;  small  fibroids;  metriti?;, 
generally  septic  in  origin  ;  retention  of  secundines  or  clots ; 
uterine  displacements ;  chronic  constipation  ;  and  the  resump- 
tion of  the  ordinary  duties  of  life  too  soon  after  abortion  or 
labor. 

Conditions  giving  rise  to  subinvolution  by  interfering  with 
uterine  contractions  are :  the  retention  of  large  clots  or  frag- 
ments of  the  placenta,  or  placentae  succenturiata? ;  displace- 
ment of  the  uterus  from  overdistention  of  the  bladder ;  large 
intramural  fibroids;  and  peritoneal  adhesions  from  old  or 
recent  inflammatory  attacks. 

Subinvolution  is  practically  always  the  result  of  some  local 
disorder.  Constitutional  disturbances  very  exceptionally  gise 
rise  to  the  condition,  though  in  women  with  general  lack  of 


TREATMENT  OF  Sl'IUXVoLrTlOX.  319 

tone,  with  flabby  ninsclcs  and  diniinislicd  cliniinatlve  pctwors, 
subinvolution  may  occur  witliout  any  evidence  of"  a  distinct 
local  cause. 

Diagnosis  of  Subinvolution. 

Tlie  diagnosis  is  usually  easy. 

By  the  tenth  day  of  the  puerperal  period  the  fundus  uteri 
shoidd  be  on  a  level  with  or  a  little  below  the  brim  of  tlie 
pelvis.  Later,  if  tlie  condition  is  suspected,  tlie  depth  of  tlie 
uterus  may  be  measured  by  means  of  the  intra-uterine  sound. 

The  lochia,  instead  of  becominjj;  pale  and  pnriform,  remains 
bloody  and  its  discharge  is  prolonged.  The  condition  is 
usually  associated  witli  constipation  and  a  coated  tongue. 

Ahlfeld  has  drawn  attention  to  the  fact  that  free  j)erspiration 
(luring  the  puerperium  is  usually  associated  with  firm  uterine 
contractions;  when  perspiration  fails  to  a])pear  lie  always  looks 
for  uterine  relaxation. 

Treatment  of  Subinvolution. 

In  the  earlier  period  of  the  puer[)eriiun  the  uterus  may  be 
stimulated  to  (;ontraction  bv  <>-entle  friction  of  the  fimdus 
through  the  abdominal  wall  for  ten  minutes  or  so,  three  or 
four  times  daily.  A  pill  containing  ergotin,  gr.  j;  ([uinine, 
gr.  j ;  and  strychnine,  gr.  T^^^y,  may  be  given  three  times  daily. 

Should  tliis  treatment  tail  to  improve  matters  and  ther^  is 
no  dimipMtion  in  the  loss  of  blood,  the  cavity  of  the  uterus 
should  be  explored  with  the  finger.  If  neces.-ary,  the  curette 
and  placental  forceps  may  be  used,  being  followed  by  a  douche 
of  hot  formalin  solution  (1  :  oOO),  and  the  introduction  of  a 
wick  of  iodoform  gauze  to  the  fundus.  The  latter  acts  by 
stimulating  the  uterus  to  contraction  and  Ivy  favoring  drainage. 
The  gauze  slioidd  be  removed  at  the  end  of  forty-eight  hours 
and  a  hot  vaginal  douche  once  or  twice  dailv  mav  be  ordered. 
Daily  free  evacuation  of  the  bowels  should  be  secured. 

If  the  uterus  be  displaced,  it  should  be  put  in  proper  position 
and  retained  tliere  by  means  of  a  pessary. 

Occasionallv  the  condition  of  subinvolution  is  not  discovered 
until  late  in  the  puerperal  period,  after  the  woman  has  been 
walking  about  for  some  time.     In  such  cases  the  cavity  of  the 


320   PATHOLOGY  OF  THE  PUERPERAL  PERIOD. 

uterus  sluuild  be  painted  witli  Clun'cliill'.s  solution  of  iodiiit , 
and  a  vai^inal  tampon  oi*  wool  saturated  with  boroglyeeriii 
should  be  inserted  two  or  three  times  a  week. 

ANOMALIES  AND  DISEASES  OF  THE  NIPPLES  AND 

BREASTS. 

Anomalies  of  the  Nipples. 

Supernumerary  nipples  are  of  frequent  oeeurreuce. 

Defects  of  the  nipples  are  chiefly  imj)ortant  as  they  mny 
interfere  with  nursinj^. 

Inversion  of  the  nipple  is  a  very  common  condition,  whi(  h 
may  be  congenital  or  acquired.  This  defect  may  constitute  ;iii 
absolute  impediment  to  lactation. 

During  the  last  month  of  pregnancy  attempts  should  be 
made  to  draw  out  the  nipples  by  means  of  a  l)reast-punip. 
When  the  nipples  are  small  or  imperfectly  (levelo})ed  daily 
gentle  traction  upon  them  by  the  nurse  or  physician  may  rcsuli 
in  improvement.  If  this  fails,  a  nipple-shield  must  be  em- 
ployed to  enable  the  child  to  nurse. 

Anomalies  of  the  Breasts. 

Absence  of  mammae:  While  imperfect  development  of  the 
mainniie  is  coiumon,  their  complete  absence  is  a  very  rare  con- 
dition. It  is  usually  associated  with  deformities  of  the  pelvic 
sexual  organs. 

Hypertrophy  of  the  i  ^ammae :  This  condition  is  also  rare. 
When  present  it  does  not  of  uecessit};  contraindicate  mn-siiiii;. 

Supernumerary  mammae:  Supernumerary  breasts  are  to  l)c 
met  with  comparatively  frequently.  They  occur  with  no 
regularity  of  situation  ;  the  most  frequent  position  is  below  the 
true  mararase;  they  have  been  found  over  the  pubes,  on  the 
buttocks,  shoulders,  and  in  the  axillae.  In  most  cases  no 
hereditary  influence  can  be  traced. 

Anomalies  in  Milk  Secretion. 

Deficient  Secretion. 

Complete  absence  of  milk-secretion  is  a  rare  condition ;  but 
deficient  milk-secretion  is  only  too  frequently  encountered. 


ANOMALIES  L\  MILK  SECRETION.  321 

Etiology  :  Lttck  of  derr/()j)in(nt  of  the  ^laiuliilur  tissue  of  tho 
hreasts  is  tlie  most  common  cause  of  deficient  secretion  of  mili<. 
This  lack  of  development  niav  he  due  to  hereditary  causes,  or 
to  c'Mitiniious  pressure  from  tiuht  clothing;  or  it  may  he 
associated  with  maldevelopment  of  the  otiier  sexual  orgaus  of 
(he  body. 

The  ,sizr  of  the  hrm.^ts  is  no  indication  of  their  ability  to 
furnish  milk.  This  function  depends  entirely  upon  the 
aiiionnt  of  glandular  t'ssue  present  in  tlui  breasts.  Some 
women  with  well-developed  breasts  have  but  little  glanduhu" 
tissue,  and  therefore  make  poor  niu'ses ;  while  others  with 
:i|)])arently  but  poor  develo|)ment  of  these  organs  have  a  rich 
and  abundant  supj)ly  of  milk  for  their  otlspring. 

The  secretion  of  milk  may  be  diminished  by  the  occurrence 
iA'  fever,  hemorrhages,  chronic;  diarrhcea,  jnid  insufficient  nour- 
ishment; serious  oi'ganie  diseases  also  result  in  diminished 
milk-secretion.  Emotions  j)rofoundly  atVect  the  secretion  of 
milk  ;  prolonged  grief  is  a  well-known  cause  of  deficient 
-ccretion. 

The  return  of  mensfrnation,  while  it  may  affect  the  quantity 
and  (jualitv  of  the  milk  secreted,  cannot  be  said  invariably  to 
|ii()duce  this  result.  Tt  may  be  stated  that,  as  a  rule,  tlie  re- 
turn of  this  function  has  but  litth;  influence  on  milk-secretion. 

Treatment :  But  little  can  be  suggested  in  the  way  of  treat- 
luont ;  good,  plain  food  and  ])lenty  of  it ;  moderate  exercise  in 
the  open  air ;  three  or  four  glasses  of  milk  daily  betw<'en 
meals,  and  a  wineglassfid  of  extract  of  malt  thrice  daily,  con- 
stitute about  all  the  treatment  ]iossible.  There  is  no  medicinal 
galactagogue  of  any  value  in  the  experience  of  the  writer. 

Excessive  Secretion — Polygalactia. 

In  this  condition,  ^vhich  is  not  infrequently  met  with,  the 
secretion  of  milk  is  in  excess  of  the  demands  of  the  child. 

Treatment :  The  bowels  should  be  kept  relaxed  and  the 
quantity  of  fluids  imbibed  reduced.  The  breasts  may  be 
coiiq)ressed  by  means  of  a  tightly  fitting  breast-binder.  The 
woman  should  take  plenty  of  hard  exercise  daily  in  the  open 
air.  If  this  treatment  fails,  the  excess  of  milk  must  be 
pumped  out  at  regular  intervals. 
21— Obst 


322        PATUOLOOY  OF  THE  PUERPERAL  PERIOD. 

Galactorrhoea. 

This  term  is  applied  to  an  excessive  secretion  of  milk  which 
persists!  after  weaning.  Tiie  flow  of  milk  is  not  necessaril\ 
ex(!ited  by  suckling  the  child.  The  milk  is  thin  and  wat(i\ . 
the  quantity  being  excessive.  One  or  more  breasts  ma\  In 
alfccted,  and  the  condition  seriously  impair  tiic  general  heahli, 
The  condition  may  last  foi*  years. 

Etiology:  Nothing  definite  is  known  as  to  the  causation  oi" 
this  condition.    It  has  been  attributed  to  a  relaxation  or  paial 
ysis  of  the  circular  muscular  fibres   surrounding  the  milk- 
ducts. 

Treatment:  These  cases  frequently  offer  very  stubborn  re- 
sistance to  all  treatment.  Firm  comj)ression  of  the  breasts  li\- 
means  of  a  breast-binder  and  the  administration  of  potassiiim 
iodide  (gr.  x  t.  i.  d.)  and  of  fl.  ext.  ergot  (Til  x).  for  a  consid- 
erable period  constitute  the  usual  treatment.  General  tonic.s 
and  iron  should  be  administered. 

Engorgement  of  the  Breasts. 

Etiology :  Reference  has  already  been  made  to  the  fact  that 
occasionally  with  the  establishment  of  lactation  the  breasts 
may  become  congested  and  engorged.  Tiiis  condition  of  en- 
gorgement may  occur  at  any  time  throughout  the  period  of 
lactation.  Exposure  of  the  breasts  to  cold  air  and  hypersecre- 
tion of  milk  are  the  most  common  causes  of  this  condition. 

Ssrmptoms:  The  breasts  quite  suddenly  become  engoriMd 
with  milk,  to  such  an  extent  as  to  occasion  very  consideialile 
distress  to  the  paticiit.  The  pain  and  tenderness  may  be  the 
o»     .ion  of  more  or  less  elevation  of  temperature. 

Treatment. 

To  relieve  the  patient  it  is  necessary  to  remove  the  excessive 
amount  of  milk  and  to  prevent  further  engorgement  of  the 
breasts.  The  breasts  may  be  emptied  by  permitting  the  infant 
to  nurse  ;  by  the  hreast-pump  ;  and  by  mascage. 

If  the  child  fails  to  empty  the  breasts,  the  milk  remaining 
may  be  drawn  off  by  means  of  the  breast-pump.     Probably 


ANOMALIES  rX  MILK  SECIiETIOX.  323 

the  most  satisfUctoiy  Invast-pump  is  that  known  as  tlie 
"Enj^lish"  piunj).  That  part  of  tlio  pump  which  is  applic*! 
to  the  breasts  sliould  he  free  iVom  ja<:!;<>;('(l,  roiij^h  od^os,  other- 
wise these  may  pnKliiee  some  al)rasions. 

Massage  of  the  breasts:  W'lien  properly  performed  this  is 
a  verv  ellieient  aid  in  relievinji;  eonm'stion  and  enirortjement. 
It  shouhl  never  he  empK)yed  if  there  is  eviilcnee  of  interstitial 
inHammation  of  the  breasts. 

'file  patient,  bein<»;  in  the  dorsal  position,  is  directed  to  sup- 
port her  l)reast  by  placing;  her  Ibrearm  under  it  and  drawin*;'  it 
lip.  The  breast  is  then  anointed,  witii  warm  oil,  afier  which 
the  operator  begins  the  manipulations  by  phicinj:;  his  finjjer- 
lips,  separated  as  widely  as  possible,  at  the  ])erij)hery  of  the 
iireast.  A  rapid  thoui^h  j^tMitle  strokinii;  luovement  is  then 
made  toward  the  nipple,  the  fino;er-tips  beini;  brought  <j;ra(l- 
iiallv  toyrether  so  as  to  nu^et  at  the  termination  of  the  stroke, 
i^ach  seij;ment  of  the  fjland  is  thus  rapidly  stroked  in  succes- 
sion, each  movement  tcrminatini>;  at  the  nij)|)lc.  The  pressure 
exerted  by  the  finger-tips  should  be  gradually  increased,  short 
dl"  producing  severe  j>ain.  This  stroking  movement  in  about 
(Ive  minutes  usually  ceases  to  cause  ])ain.  Then  the  operator 
sii|)j)orting  the  breast  in  the  palm  of  one  hand,  with  the  iinger- 
tips  of  the  other  hand  selects  a  nodiifc  of  induration,  which  he 
strokes  toward  the  nipple,  gradually  employing  deeper  and 
liiiner  pressure.  Each  nodule  of  induration  is  thus  treated  in 
succession. 

Xodules  M'hieh  this  mapii)ulation  fails  to  soften  may  then 
!)(•  compressed  by  placing  the  hand  flat  ui)on  them  and  exerting 
st(  ady  gentle  pressure  downward  against  the  chest-wall.  The 
pivssure  thus  exerted  should  be  greatest  at  the  periphery  of  the 
i;l;iiid.  After  a  few  moments  of  steady  j)ressure,  gentle  rotary 
movements  of  the  hand  may  be  made  over  the  lum])s.  If  pain 
is  complained  of,  the  stroking  movements  should  be  resumed. 

The  breast  should  then  be  grasped  with  both  hands  so  as  to 
encircle  it  completely ;  and  the  whole  gland  gently  raised  and 
(oinpressed,  while  the  two  index-fingers  are  quickly  stroked 
toward  the  nipple  to  favor  the  escape  of  milk.  These  various 
manipulations  should  be  repeated  at  short  intervals  until  the 
glands  have  been  softened  and  emptied  of  their  contents,  when 
a  pressure-bandage  should  be  applied. 


324        PATHOLOGY  OF  THE  VVERPERAL   PERIOD. 


The  most  satisfactory  breast-bandage,  in  the  opinion  of  tlio 
writer,  is  the  Y-han<hi^(',  which  was  first  t'ni|)h)y('(l  in  tin 
Hoslon  livin^-in  II(.sj)il;il.  Tiiis  may  1)C  made  of  two  jticcLs 
of  soft,  nni)lcaciic(l  cotton  <n*  bird's  eye  toweilini;,  a!)(»iit  tiiirtv- 
six  inciics  ionj^  and  ten  or  twcisc  inciics  wide.  I  iiave  used 
ordinary  hand  towels  tor  this  pnrj)()se,  and  lind  they  answi  r 
admirably.  Tiiese  are  fohled  into  strips  ahont  three  or  fi.iii' 
inches  wide;  one  of  these  is  fohhsd  end  to  end,  and  tiie  douMd 
end  turned  ovei'  so  as  to  convert  the  strip  into  an  L-sh;i|M , 
wlicn  tlie  free  ends  arc  separated.  'V\\v  apex  of  tiiis  .'-tii|)  i- 
tlien  pinned  with  tiiree  or  four  safety-pins  to  one  end  of  tin 
other  strip,  so  as  to  form  tii<.'  Y-l)an(lagc. 

The  breasts  are  then  (lasted  witli  powdered  stardi  or  otin  r 
dusting-powder,  and  the  hmocr  arm  of  tlie  baiuhige  sli|>|i((| 
under  the  patient's  baciv  at  tiie  lower  part  of  the  scM|iiil;ir 
region  until  the  apex  of  the  fork  is  just  external  to  the  oiilcr 
edge  of  the  left  breast.  The  [)Mtient  then  lifts  her  brea-ts 
upward  and  toward  each  other,  while  the  lower  arm  of  the 
fork  is  drawn  tightly  across  the  chest  beneath  the  breasts;  \\\v 
inferior  border  of  this  arm  shotdd  extend  at  least  an  inch  below 
the  lower  margins  of  the  breasts. 

The  upper  arm  of  the  fork  is  then  drawn  across  the  chest 
above  the  breasts  in  such  a  way  that  its  upjter  border  exteixU 
an  inch  beyond  the  u])per  margins  of  the  breasts.  The  iVeo 
ends  of  the  two  arms  of  the  fork  should  thus  meet  at  the  outer 
margin  of  the  right  breast,  where  they  shoidd  then  be  drawn 
tight  and  securely  pinned  with  safety-pins  to  the  strip  wiiicji 
lias  been  passed  l)eneath  the  back.  The  free  end  of  the  l);i  •!< 
stri])  may  then  lie  over  the  apices  of  both  breasts.  The  >tii[) 
passing  underneath  the  breasts  is  then  pinned  to  the  binder  to 
keep  it  from  slipping  up;  shoidder-straj)s  may  then  be  pintud 
to  the  upper  arm  of  the  fork  and  fastened  behind  to  the  l»:i(k 
strij)s,  thus  kcej)ing  the  upi)er  arm  of  the  ibrk  from  sli|>|»iiig 
down.  The  hollow  between  the  breasts  may  then  be  filled  with 
cotton,  and  this  held  in  place  by  two  safety-])ins  joined  togetlicr 
and  pinned  to  the  u})per  and  lower  arms  of  the  fork. 

In  place  of  this  the  Murphy  binder  may  be  employed.  It  is 
made  of  a  strip  of  thick  gray  c<)ttt)n,  forty  inches  long  and  ton 
inches  wide.  In  the  upper  border  of  this  stri])  a  narrow  notch 
is  cut  for  the  neck,  and  two  deep  notches  for  the  arms.     The 


soiii':  MrrLix 


32.") 


hinder  is  a|)|ili('<l  ti^litly  over  tlic  breasts  and  pinned  in  front. 
W'licn  it  is  desired  to  iiiaUe  applications  to  tiie  nippies,  (wo 
cirenlar  iioles  tiie  size  of  a  silvei'  iiaif  dollar  can  he  ent  in  the 
Mur|»liy  hindei";  the  margins  ot"  tlieso  iioles  shonld  he  hntt^Mi- 
liole  stiteiied. 

In  eax's  in  which  tli«'  en<i[;orge!nent  is  intense  and  the  breasts 
-()  sensitive  that  nianipidation  is  impossible  nnich  I'l-licf  can  be 
iiv<'n  by  the  application  of  hot  compresses.  Flannel  soaked 
III  hot  water  and  carbonate  of  ammoninm  (."j  to  tiie  pint), 
wrnng  dry,  and  then  api)lied  to  th(>  l)reasts,  and  repeated  at 
Intervals  of  live  minntes,  soon  gives  relief  and  permits  the 
ipplication  of  the  bi'east-binder. 

In  these  cases  a  frrc  aclion  of  the  hoiir/.s  shonld  be  obtained 
hy  the  administration  of  teaspoonfnl  doses  of  Jxochelle  salt  in 
warm  water,  at  intervals  of  fifteen  minutes  till  ])nrgati(»n  is 
i  I  III  need. 

Sore  Nipples. 

Etiology  and  symptoms:  The  child  in  mirsing  may  niacer- 
;ile  the  sni)erficial  ej>ithelinm  of  the  nipples.  Small  superficial 
ulcers  may  thus  be  formed  at  the  apices  or  at  the  bases  of  the 
nipples,  which  arc  dillicnlt  to  heal  because  the  child  in  nursing 
Mjiarates  their  edges.  The  j)ain  canse<l  by  this  condition 
varies  between  siin])le  tenderness  at  the  moment  the  cliild 
sizes  the  nipj)le,  and  the  acutcst  agony  during  the  whole  act 
of  suckling.  Erosion  of  the  nipples  occurs  most  frequently 
ill  primiparte. 

Treatment. 

Prophylactic  treatment  should  be  begun  toward  the  end  of 
invgnancy,  as  has  been  mentioned.  Close  attention  to  cleans- 
ing of  the  ni|)j)les  and  of  the  child's  mouth  is  of  supreme  im- 
poitance.  After  nursing,  the  ni|)ples  should  be  washed  with 
Ixirie-aeid  lotion  and  carefuily  dried.  At  least  once  a  day  the 
cliild's  moijth  should  be  swabbed  with  pledgets  of  cotton  soaked 
in  glycerinum  boracis.  The  bismuth  paste  recommended  in  the 
section  on  JNIanagement  During  the  Puerperal  Period  may 
he  employed,  following  tlie  precautionary  cleansing  after  nurs- 
ing. To  this  ointment  it  may  be  w^ell  to  add  balsam  of  Peru 
(.>ss)  sliould  there  be  evidence  of  abrasion. 


326        PATHOLOGY  OF  THE  PUERPERAL  PERIOD. 

Painting  the  nipples,  by  means  of  a  camel's-liair  l)riit^li,  with 
the  coiii|)(tuii(l  tincture  of  benzoin,  or  a  10  grain  to  tiie  ouik. 
solution  of  silver  nitrate,  will  be  fount!  very  satisfactory  treat- 
ment in  more  severe  oases.  Deep  fissures  are  best  treated  li\ 
daily  touching  them  carefully  with  the  solid  stick  of  nitrate 
of  silver. 

In  some  cases  extreme  tenderness  of  the  nipples  niav  li 
complained  of,  and  yet  the  most  careful  examination  fail  i  . 
reveal  any  trace  of  either  erosion  or  fissure.  In  tluw.'  ca-  > 
extract  of  witch-hazel  (ext.  hamamelidis)  will  be  found  v<i\ 
useful ;  it  may  be  employed  pure  or  diluted  with  two  or  three 
parts  of  boiled  water. 

The  writer  has  had  very  satisfactory  results  from  paint iiiu- 
the  tender  nipples  with  a  satura<^*;d  alcoholic  solution  of  ortho- 
form,  at  least  as  far  as  giving  relief  from  pain  while  nursing  i.s 
concerned.  This  should  be  applied  with  a  camel's-hair  bru>li 
just  before  each  application  of  the  child  to  the  nipple.  Cer- 
tain writers  claim  to  have  had  severe  inflammatory  react  inn 
follow  its  employment,  so  that  it  should  always  be  used  wit!i 
caution. 

In  all  cases  in  which  the  ni})ples  are  tender  a  glass  and  iiili- 
ber  nipple-shield  should  be  employed  while  nursing.  The  shi(^M 
should  be  kept  surgicaliy  clean. 

In  some  cases  it  may  bo  necessary  for  the  mother  not  even 
to  attempt  to  nurse  tlie  child  for  twenty-four  hours,  or  e\eM 
longer.  In  these  cases  the  breasts  may  be  emptied  by  menus 
of  massage,  the  breast-pump  not  being  used  unless  it  piovo 
absolutely  necessary. 

In  very  exceptional  cases  nothing  but  weaning  will  result  in 
permanently  relieving  the  condition. 

loflammation  of  the  Breasts — Mastitis. 

Varieties:  Three  forms  of  mastitis  are  usually  dcscrilMil: 
the  most  frequent  variety  is  the  parencJnpnafoKi^,  or  (f/an(hi/<ii\ 
in  which  the  acini  of  the  gland  are  primarily  the  site  of  tlic 
inflammation.  In  the  subcutaiicous  variety  the  connective 
tissue  immediately  beneath  the  skin  is  attacked.  In  the  -^I'l)- 
(/landnlar  or  post-mammari/  form  the  connective  tissue  between 
the  gland  and  the  chest-wall  is  the  site  of  the  inflammation. 


INFLAMMATION  OF  THE  BREASTS-'-MAS'^rTIS.      327 

Tlie  inflamniation  is  but  rarely  confined  to  one  of  these  lo- 
calities, so  that  clinically  two  or  all  three  may  be  combined, 
especially  in  cases  which  do  not  receive  prompt  treatment. 
Usually  mastitis  begins  in  the  acini  of  the  gland,  whence  it 
spreads  to  the  connective  tissue  and  approaches  the  skin  sur- 
face. 

Frequency:  Mastitis  occurs  in  about  6  per  cent,  of  all  nurs- 
ing women,  though  it  is  most  frequently  met  with  in  prim- 
iparte.     It  may  terminate  by  resolution  or  by  suppuration. 

Etiology:  All  forms  of  mastitis  are  of  microbic  orU/hi,  The 
infection  is  usually  due  to  the  entrance  of  staphylococci,  either 
the  aureus  or  albus,  though  streptococci  or  other  j)Us-producing 
organisms  may  give  rise  to  the  condition. 

The  infection  usually  arises  in  a  fissure  or  abrasion  of  the 
nipple,  and  spreads  either  by  means  of  the  lymph-chanm'k  into 
the  connective  tissue;  or  directly  along  the  epithelium  of  a 
dud  to  an  acinus,  possibly  to  several.  The  inflammation  may 
ai  first  be  confined  to  the  epitheliimi,  but  soon  spreads  to  the 
surrounding  connective  tissue.  Impaired  general  health  and 
local  mechanical  injuries  are  important  predisposing  causes. 

Mill:  stasis  was  at  one  time  thought  to  be  the  cause  of  mas- 
titis, but  pathologists  have  proved  that  stasis  alone  will  not 
j)roduce  the  condition.  It  is  possible  that  stasis  of  milk  results 
in  impairment  of  the  epithelium  of  the  ducts  and  thus  renders 
infection  more  liable  to  occur. 

A  possible  source  of  infection  is  the  blood.  Escherich  slates 
that  staphylococci  which  have  gained  access  to  the  blood 
tiu'ough  infection  of  the  genital  canal  are  excreted  in  the  milk. 

Symptoms  of  Mastitis. 

All  forms  of  mastitis  are  accompanied  by  the  signs  of 
inflammation. 

The  onset  of  the  inflammation  is  generally  characterized  by 
;i  distinct  chill  or  by  a  sense  of  chilliness.  The  temperature 
begins  to  rise  and  the  patient  complains  of  pain  and  tenderness 
in  the  affected  breast.  < 

In  the  parenchymatous  form  one  or  more  tender  nodules  will 
be  found  in  the  affected  breast.  The  skin  overlying  these  nod- 
ules may  or  may  not  be  reddened.     Pressure  on  these  nodules 


328        PATHOLOGY  OF  THE  PUERPERAL  PERIOD. 

usually  produces  a  sliarj),  cutting  paiu.     The  temperature  may 
rise  to  104°  F.,  or  even  higher. 

In  the  low  interstitial  form  the  pain  is  not  so  distinctly  local- 
ized and  no  nodule  can  he  lelt  in  the  breast.  The  temperature 
rises  more  gradually  and  chilly  sensatioiis  are  more  frequciii 
than  a  distinct  rigor.  The  skin  oven'  the  affected  area  quicklv 
becomes  reddened,  and  it  will  be  frequently  noticed  that  the 
site  of  the  inflammation  corresponds  to  a  fissure  in  the  nij>j»l( . 
This  form  of  inflammation  is  very  difficult  to  abort  and  u.-u- 
aiiy  results  in  abscess  formation,  though  if  the  breast  be  opened 
early  but  wry  little  pus  may  be  found. 

Treatment  of  Mastitis. 

Abortive  :  The  iuelications  are  to  secure  complete  rest  for  tlio 
affee;ted  glanel  by  (a)  absolutely  prohibiting  nursing  from  cither 
breast;  {h)  removing  by  means  of  massage  and  the  brca>t- 
pump  the  contents  of  the  glands,  and  (c)  reducing  the  local 
blood-supply. 

It  is  imjiortant  to  decide  if  possible  whether  the  inflamma- 
tion is  of  the  parenchymatous  or  of  the  interstitial  form.  The 
mode  of  onset,  condition  of  the  nijiple,  appearance  and  feel  of 
the  breast,  anel  the  fact  that  the  parenchymatous  form  occurs 
most  frequently,  will  afford  assistance  in  making  a  diagnosis. 

If  the  type  of  inflammation  present  is  parenchymatous,  the 
routine  of  treatment  may  be  given  as  follows :  the  breasts  aic 
emptied  by  means  of  massage  and  the  breast-pump,  all  manipu- 
lations being  as  gently  carried  out  as  possible.  The  nij)j)l(> 
are  then  cleansed  and  an  antiseptic  dressing  applied,  as  pre- 
viously re^commended.  A  tightly  fitting  Murphy  binder  is 
then  applied  so  as  to  secure  as  firm  compression  of  both  breasts 
as  is  })ossible,  without  increasing  the  j)ain  i.i  the  affected  parts. 
Then  an  ice-bag  may  be  placed  outside  the  binder  over  tlic 
affected  portion  of  the  gland.  The  ice-bag  should  be  kejit 
constantly  applied  for  from  twelve  to  twenty-four  hours,  the 
length  of  time  being  eletermined  by  the  relief  of  pain  and  sub- 
sidence of  temperature. 

The  lessening  of  the  local  blood-supply  of  the  gland  may 
be  obtained  bv  the  derivative  action  of  saline  cathartics,  which 
should  be  freely  administered  as  previously  recommended. 


INFLAMMATION  OF  THE  BREASTS— MASTITIS.      ;}29 

If  after  twenty-four  hours  tlie  temperature  lias  dropped  and 
the  paiu  disappeared,  tlie  pressure  on  tlie  breasts  may  he  re- 
duced by  loosening  the  binder  somewhat.  The  ice-bag  may 
then  be  removed  for  an  hour  or  two,  but  should  be  used  inter- 
mittently till  all  tenderness  of  the  breast  disappea/s  and  the 
flow  of  milk  has  been  re-established.  In  rare  instances  the  ice- 
l)ag  is  not  well  borne  by  the  patient,  in  which  case  a  com|)ress 
wrung  out  of  a  solution  of  lead  and  opium  (1  :  40)  should  be 
applied  over  the  affected  portion  of  the  gland  and  (;overed  with 
oiled  silk  or  a  layer  of  non-absorbent  cotton,  over  which  the 
Murphy  binder  may  be  lightly  applied. 

The  treatment  of  the  interstitial  form  of  mastitis  differs 
somewhat  from  the  preceding.  In  this  form  massage  should 
))(>  avoided,  as  only  tending  to  aggravate  the  condition.  The 
Murphy  binder  should  be  applied  so  as  merely  to  support  the 
breasts,  but  not  to  compress  them  ;  otherwise  the  treatment  of 
the  two  forms  is  the  same.  In  spite  of  all  treatment  a  large 
proportion  of  these  cases  terminate  in  abscess  tbrmation. 

Mammary  Abscess. 

The  pus  may  be  located  in  the  gland-substance  or  in  the 
>ul)mammary  connective  tissue. 

Symptoms:  It  is  not  always  possible  to  be  certain  that  sup- 
|)>u'ation  has  taken  place  from  the  symptoms  given.  Fluctua- 
tion, the  most  certain  sign  of  abscess  formation,  is  rarely  to  be 
jinnid  until  late. 

Severe  throbbing  or  stabbing  pain  suggests  abscess  forma- 
tion, especially  when  accompanied  with  chilly  sensations,  a 
iiigher  grade  of  temperature,  and  greater  ra])idity  of  pulse. 
Tsually  a  bluish  discoloration  and  some  oedema  of  the  skin 
mark  the  locality  where  the  abscess  will  "  point,"  especially  in 
the  more  common  parenchymatous  form. 

In  the  interstitial  fomn  the  pus  tends  to  burrow  extensively, 
and  no  actual  abscess  may  be  discernible  though  the  whole 
^dand  is  found  to  be  riddled  with  pus-tracts.  If  such  a  case  be 
left  too  long,  the  pus  will  be  found  "  pointing  "  in  several  })laces. 

Surgical  Treatment. 

Preliminary:  The  patient  should  always  be  anresthetized 
before  attempting  to  open  or  treat  a  mammary  abscess,  unless 


;i30   PATHOLOGY  OF  THE  PUERPERAL  PERIOD. 

it  be  superficial  and  about  to  point.     The  wliole  breast  should 
b(,'  well  scrubbed  with  soap  and  hot  water,  followed  by  solii 
tions  of  permanganate  of  potassium  and  oxalic  acid. 

Incision:  By  carel'ul  palpation  the  pus  collection  is  located, 
and  an  incision  is  then  made  in  the  skin  over  its  most  de[)(ii 
dent  portion  in  a  line  radiating  from  the  nipple.  Through  tiiis 
opening  a  grooved  director  is  then  inserted  and  passed  in  all 
directions  until  pus  is  encountered,  when  a  pair  of  arterv- 
forceps  is  introduced  and  opened  so  ps  to  dilate  the  ti^siK  - 
sufficiently  to  permit  the  introduction  of  a  finger  iiiiu 
the  abscess-cavity.  All  adjacent  cavities  should  then  lie 
searched  for  and  freely  opened,  and  all  friable  tissue  britkcn 
down.  Additional  openings  should  be  made  to  secure  five 
drainage.  The  walls  of  the  abscess-cavity  should  be  geiiilv 
scraped  with  a  Volkmaun  spoon.  All  the  openings  shoultl 
then  be  irrigated  freely  with  an  antiseptic  solution,  such  us 
formalin,  1  :  500. 

Drainage:  Instead  of  employing  rubber  tubes  for  drainage, 
gutta-percha  tissue  which  lias  been  stei'ilized  by  soaking  in 
formalin  solution,  and  then  folded  in  strips  about  half  an  inch 
wide  and  six  or  eight  inches  long,  will  be  found  much  more 
serviceable.  Several  of  these  strips  should  be  drawn  throiiuli 
the  openings,  so  as  to  secure  drainage  in  all  directions.  An 
antiseptic  surgical  dressing  is  then  applied,  and  the  breast 
firmly  bandaged  with  a  broad  roller  bandage,  so  as  to  secure 
even  compression  throughout,  or  a  Murphy  bandage  may  I)o 
applied. 

After  twenty-four  or  thirty-six  hours  the  dressings  should  ho 
removed  and  the  abscess-cavity  thoroughly  irrigated  with  boric- 
acid  or  formalin  solution.  The  gutta-percha  tissue  drains 
should  be  reinserted  and  a  fresh  dressing  applied.  As  soon  as 
the  discharge  has  almost  ceased,  the  gutta-percha  tissue  drain- 
age may  be  dispensed  with  and  firm  compression  of  the  walls 
of  the  cavity  secured  by  means  of  antiseptic  compresses  placfd 
under  the  bandage  or  binder.  The  most  equable  pressure  is 
secured  by  means  of  a  large  bath-sponge  which  has  been  boiled 
and  then  wrung  out  of  1  :  5000  bichloride  solution.  Tliis 
should  be  slightly  hollowed  out  so  as  to  fit  over  the  breast,  to 
which  it  is  directly  applied  and  covered  with  oiled  silk  and  the 
bandage  or  binder.     This  dressing  should  be  removed  daily 


ARREST  OF  LACTATION.  331 

and  the  sponge  cleansed  in  ii  solution  of  1  :  5000  l)iehloride. 
The  breast  should  also  be  washed  with  the  same  solution 
before  the  dressinj^  is   reapplied. 

Nursing:  The  child  may  be  applied  to  the  sound  breast  to 
keep  up  the  flow  of  milk,  provided  the  mother's  general  health 
is  such  that  it  is  not  desirable  to  discontinue  nursing. 

In  the  interstitial  form  ci"  abscess  but  very  little  pus  may 
be  found  on  incising  the  breast.  All  nodules  should  l)eopened> 
as  the  pus  tends  to  burrow  very  extensively  in  this  form,  and 
special  care  should  therefore  be  given  to  providing  for  free 
drainage. 

Abscesses  of  the  areola :  The  glands  of  Montgomery  may 
become  infected  and  result  in  the  formation  of  small  superficial 
abscesses  in  the  areola. 

Trcotment :  Each  suppurating  gland  should  be  o})ened,  and 
its  walls  curetted  and  then  swabbed  with  strong  bichloride  or 
formalin  solution. 

Galactocele :  This  is  a  milk  tumor  which  may  form  as  the 
result  of  occlusion  of  one  of  the  lactiferous  ducts.  Beyond 
causing  a  little  pain  these  milk  tumors  are  of  no  importance. 

7yT«^w<'7*/ .•;  Massage  may  result  in  causing  the  milk  to  flow 
and  thus  relieve  the  condition.  Karely  these  tumors  persist 
for  a  long  time,  and  may  become  so  large  as  to  necessitate 
their  being  tapped  and  drained. 

Arrest  of  Lactation. 

Indications:  When  the  child  has  perished  at  birth  or  when 
the  constitutional  condition  of  the  mother  is  such  as  to  pre- 
clude the  possibility  of  nursing,  it  is  necessary  to  prevent  the 
activity  of  the  mammary  glands. 

Method :  Before  the  first  aj)pearance  of  breast  engorgement 
a  tightly  fitting  Murphy  hinder  should  be  applied.  Free 
jiiirgation  should  be  induced  by  means  of  salines  when  the 
patient's  strength  will  permit.  The  amount  of  fluids  ingested 
-liould  be  restricted,  the  patient's  thirst  being  relieved  by 
rinsing  the  mouth  frequently  with  weak  tea. 

If  the  engorgement  of  the  breasts  tends  to  become  excessive, 


;}32   PATHOLOGY  OF  THE  PUERPERAL  PERIOD. 

the  binder  may  be  removed  once  or  twice  daily  to  permit  of 
mcmmf/e  or  the  u.se  of  the  bread-pwinp.  Tlie  breasts  may  tlioii 
be  covered  with  glycerite  of  belladonna  and  tiie  binder  or 
bandaj^e  reapplied.  Usnally  under  this  treatment  the  breasts 
become  inactive  in  less  than  a  week. 

To  arrest  lactation  when  the  woman  has  been  narshir/  for 
some  time,  firm  compression  of  the  breasts  by  means  of  tlic 
Y-binder  combined  with  the  use  of  salines  will  be  sufficient. 
Tlio  milk  usually  flows  away  readily  under  the  compression 
exerted  by  the  Y-binder,  and  there  is  no  disposition  of  the 
breasts  to  become  engorged  and  caked. 

Massage  and  the  use  of  the  pump  siiould  be  omitted  as 
long  as  the  milk  flows  away  freely.  In  a  few  days  the  breasts 
will  cease  flowing,  when  a  Murphy  binder  may  be  applied  ami 
worn  till  the  breasts  become  soft. 

After  prolonged  lactation  there  is  but  little  difficulty  in 
drawing  away  the  milk  when  the  child  is  weaned  gradually. 
Should  secretion  ])ersist  it  may  be  necessary  to  employ  com- 
pression and  to  give  atropine  internally. 

INTERCURRENT   DISEASES   IN   THE   PUERPERIUM. 

Miscellaneous  Diseases. 

Scarlet  fever :  This  is  a  rare  complication  of  the  puerpcriiim. 
It  almost  always  appears  within  three  days  of  labor ;  tlie 
throat  complications  are  slight,  the  rash  appears  quickly,  is 
rapidly  diffiised,  and  is  usually  of  an  intense  dark-red  color. 
Convalescence  is  usually  tedious.  Occasionally  the  pelvic 
organs  are  profoundly  affi.vted  by  this  disease,  and  when  this 
is  the  case  the  prognosis  is  very  grave. 

When  the  attack  is  a  frank  one  and  the  genitalia  are  not 
much  involved  the  prognosis  is  not  unfavorable,  though  the 
condition  is  a  grave  one. 

Measles  :  The  puerperium  is  rarely  complicated  by  this  dis- 
ease unless  the  attack  has  occurred  during  ]>regnancy  and  has 
led  to  premature  expulsion  of  the  ovum.  The  condition  pre- 
disposes to  hemorrhage  and  also  to  pneumonia. 

Variola :  This  is  a  very  grave  complication  of  the  puer- 
perium. 


MISCELLANEOUS  DISEASES.  333 

Rotheln :  This  disease  does  not  markedly  aifect  the  puer- 
periiim.  In  two  or  tlireo  cases  which  have  come  under  my 
notice  the  disease  was  very  mild  in  character,  though  in  one 
the  rash  was  very  marked. 

Erysipelas:  This  disease  usually  affects  the  genitals  when 
it  occurs  during  the  puerperal  jjcriod.  It  is  seldom  mani- 
fested by  a  cutaneous  eruption.  When  the  genitals  only 
are  aife(^ted  the  prognosis  is  very  grave,  and  it  is  imjH)ssil)le 
to  distinguish  the  case  from  one  of  ordinary  streptococcus 
infection. 

Erythematous  rashes :  Puerperal  erythema  is  not  an  infre- 
quent condition. 

In  rshnplc  cases  there  is  apt  to  he  a  moderate  elevation  of 
temperature,  and  the  lochia  may  become  offensive.  There 
may  be  some  uterine  or  pelvic  tenderness.  The  condition  is 
therefore  looked  upon  as  a  mild  septic  infection. 

Iodoform  when  freely  used  about  the  genitals  may  set  up 
an  extensive  erythematous  rash  ;  in  this  aise  the  temperature 
and  pulse  remain  unaffected  unless  the  skin  irritation  causes 
the  patient  much  distress. 

Erythema  may  be  mistaken  for  scarlet  fever,  and  it  is  not 
infrequently  associated  with  grave  septicaemia. 

Diphtheria :  This  disease  may  affect  the  throat  or  the  genitals, 
in  the  latter  case  a  variety  of  general  sepsis  ensues. 

Pneumonia:  This  disease  constitutes  a  very  grave  complica- 
tion of  the  puerperium.  It  not  infrequently  occurs  secondary 
to  septic  infection.  Its  treatment  will  be  discussed  in  the 
section  on  puerperal  infection. 

Rheumatism;  arthritis:  The  diagnosis  between  septic  arthri- 
tis and  simple  acute  rheumatism  is  a  matter  of  great  difficulty 
during  the  puerperium.  Sim])lc  rheumatism  tends  to  affect 
several  joints,  while  the  arthritis  is  septic  in  origin  and  usually 
only  one  large  joint  is  affected.  In  the  latter  case  there  may 
be  little  evidence  of  general  septic  infection.  Simple  rheuma- 
tism usually  runs  its  ordinary  course  and  does  not  affect  the 
puerperium,  nor  is  it  affected  greatly  by  it. 

The  treatment  of  acute  rheumatism  is  the  same  as  when  it 
occurs  at  any  other  time.  In  septic  ai'thntis  recovery  is  the 
rule,  but  with  a  greatly  damaged  joint.  Local  treatment  only 
is  of  service^  general  medication  being  of  little  use. 


334       PATHOLOGY  OF  THE  PUERPERAL  PERIOD, 

Malaria. 

The  puerperal  state,  it  is  generally  admitted,  predisposes  to 
malarial  attacks.  Women  who  are  subject  to  malaria  usually 
manifest  the  disease  after  delivery,  probably  as  a  result  of  tlie 
traumatism  of  labor. 

The  malarial  attack  is  usually  of  a  mild  type,  but  occasion- 
ally it  may  be  extremely  severe.  The  disease,  which  usual Iv 
manifests  itself  about  the  third  day  after  delivery,  prcdisposi  s 
to  puerperal  hemorrhage;  it  also  modifies  milk  secretion,  espe- 
cially during  the  exacerbation  of  fever.  It  is  not  general  Iv 
admitted  that  the  germs  of  disease  can  be  transmitted  in  thf 
milk  to  the  nursing  infant. 

Diagnosis :  Malaria  occurring  during  the  puerperium  nni>t 
be  differentiated  from  septic  infection  or  typhoid  fever.  Tlic 
diagnosis  is  occasionally  a  matter  of  considerable  difficulty. 
The  fever  in  malaria  is  frequently  continuous  at  first,  but  soon 
becomes  remittent  in  type. 

In  doubtful  cases  the  blood  should  be  examined  for  malarinl 
organisms,  and  Widal's  test  for  typhoid  reaction  should  he 
applied.  A  bacteriological  examination  of  the  uterine  locliia 
should  also  be  made,  for  it  is  quite  possible  that  malarial  pois- 
oning may  be  associated  with  septic  infection  in  some  cases. 
With  these  tests  at  one's  disposal  we  should  not  remain  long  in 
doubt  as  to  the  origin  of  the  fever  in  any  given  case. 

Treatment:  Usually  it  is  necessary  to  give  large  doses 
of  quinine  to  control  the  fever  during  the  puerperium. 
When  the  daily  dose  of  quinine  is  20  grains  or  under,  it  is 
seldom  necessary  to  remove  the  child  from  the  breast ;  but 
when  this  dose  is  exceeded  the  infant  is  likely  to  suffer  from 
the  effects. 

Puerperal  Anaemia. 

After  delivery  the  blood  begins  to  undergo  a  change  in  con- 
stitution by  which  it  is  converted  from  the  hydrsemia  of  pre<;- 
nancy  to  the  normal  proportion  of  its  constituent  parts  in  the 
non-gravid  condition. 

This  change  is  usually  completed  by  the  end  of  the  second 
week  of  the  puerperal  period. 

Many  causes  may  interfere  with  this  process  of  involution 


:( 


M 


DISEASES  OF  THE  VRTXARY  ORGAXS.  335 

of  the  blood,  such  as  sepsis,  severe  blood-loss  at  the  time  of 
labor,  or  any  wasting  or  depressing  disease.  In  such  cases 
the  anaemia  tends  to  assume  a  pernicious  form  if  treatment  ib 
neglected. 

Careful  blood  examinations  should  be  made  from  time  to 
time  in  these  cases  in  order  to  judge  of  the  effect  of  treatment. 

The  treatment  consists  in  the  administration  of  tonic  drugs 
and  careful  feeding.  Iron  and  arsenic,  in  the  form  of  the  com- 
pound .Bland  pill,  usually  give  satisfactory  results.  In  some 
eases  in  which  iron  is  not  well  borne  ai*senic  alone  will  succeed. 

Hemorrhoids. 

Great  discomfort  is  frequently  caused  by  an  attack  of  hem- 
orrhoids during  the  earlier  days  of  the  puerperal  period. 

Treatment :  The  bowels  siiould  be  freely  opened,  and  great 
relief  may  be  obtained  by  the  application  of  hot  compresses 
wrung  out  of  hot  lead-and-opium  solution  (1:40).  In  some 
cases  the  application  of  ice  is  more  comforting  to  the  patient. 
An  ointment  composed  of  equal  parts  of  ung.  gallfB  cum  opio, 
uug.  stramon.  and  ung.  bellad.  will  further  relieve  pain. 

Diseases  of  the  Urinary  Organs. 

Retention  of  urine :  Patients  not  infrequently  complain  of 
inability  to  urinate  after  delivery.  The  condition  may  be  the 
result  of  injury  to  the  urethra  or  the  anterior  vaginal  wall 
during  labor.  Many  women  are  unable  to  empty  the  bladder 
while  lying  in  bed.  In  others  the  flow  of  the  urine  over 
small  abrasions  of  the  vulva  sets  up  irritation,  which  they 
seek  to  avoid  by  holding  the  urine  as  long  as  possible.  The 
relaxed  condition  of  the  abdominal  walls  and  the  consequent 
diminution  of  intra-abdominal  pressure  to  some  extent  inter- 
fere with  the  function  of  micturition  during  this  period. 

Treatment:  The  nurse  should  be  instructed  to  see  that  the 
patient  empties  the  bladder  at  least  twice  daily.  For  this  pur- 
pose, if  unable  to  pass  water  otherwise,  the  patient  may  assume 
a  kneeling  posture,  or  may  be  raised  carefully  so  as  to  be  able 
to  sit  on  the  bed-pan.  Hot  applications  may  prove  of  assist- 
ance, as  may  also  the  stimulus  caused  by  the  sound  of  running 


ii.J()        PATHOLOGY  OF  THE  PUERPERAL  PERIOD. 

water.  If  tliese  means  fail,  the  nurse  should  be  instructod  to 
])ass  the  catiietcr  into  the  bladder,  and  to  observe  the  strietcst 
antiseptic  pi'ccautions  in  so  doinj^. 

Incontinence  of  urine  :  Tiiis  condition  may  result  from  ovt  r- 
distention  ol'  the  bladder  from  retention  of  urine.  This  is  tin- 
commonest  cause.  Other  causes  of  tlie  condition  are  paresis  of 
tile  spiiincter  muscle  and  vesicovaginal  or  vesico-uterine  fistula. 

A  ('(ir<fi(/  c.vdviinatlon  will  reveal  the  cause  of  the  condition. 
Tiie  firdhnent  nuist  vary  with  the  cause  of  the  incontinence. 

Cystitis:  This  is  untbrtunately  a  connnon  complication  of 
the  puerperal  state.  It  is  usually  due  either  to  injury  from 
overdistention  of  the  bladder  or  to  careless  catheterization. 

S//iiij)fo)iis :  Frequent  micturition,  associated  with  buriiiiiir 
and  tenesmus,  is  the  most  usual  symptom;  the  temperatuiv 
may  rise  to  1()2°-103°  F.,  and  the  pulse  become  rapid.  The 
uriiu;  is  usually  found  to  contain  mucus  and  pus  in  varying 
(piantities. 

Trciitinod :  Prompt  and  eneri2:;etie  treatment  is  usually  lie- 
manded  to  ]>revent  the  infection  spreadinji;  to  the  ureters  and 
kidneys.  The  bladder  should  be  irrigated  daily  with  a  waiiii 
solution  of  boric  acid  (gr.  xv-.^j).  The  diet  should  consist  of 
milk  only,  and  the  following  mixture  should  be  ordered  : 

^.  Sod.  bibor., 

Ac.  benzoic,  aa  .fss  ; 

Inf.  buchu,  5vj. — M. 

Sig.  A  tablespoonful  in   a  wineglassful  of  water  three 
times  daily. 

If  the  condition  persist  after  irrigating  with  boric  solution, 
the  bladder  should  be  distended  with  a  solution  of  silver  nitrate 
(gr.  ss-^j),  all  of  which  should  be  allowed  to  drain  away  with 
the  exception  of  about  an  ounce,  which  may  be  left  in  the 
bladder. 

Pyelonephritis :  This  condition  may  follow  an  infection  of 
the  bladder  by  extension  of  the  disease  along  the  ureters,  or  it 
may  result  from  a  general  septic  infection. 

Diacpiosls  can  usually  be  made  by  an  examination  of  the 
urine. 

Treatment:    Stimulation,   support,    the    administration    of 


DISEASES  OF  THE  NERVOUS  SYSTEyf.  Il'i? 

hliiiid  diuretics,  and  daily  iirit;ati()ii  of*  the  bladder  constitute 
tlio  treatment  of  tiiis  condition. 

Hsematuria  :  Bloody  mine  is  sometimes  seen  af'tef  labor,  and 
may  tbllow  severe  contusion  ot'tlic  bladder  either  l)y  the  child's 
head  or  the  forceps.  Not  intVe(|iiently  tlie  condition  is  due  to 
the  jx'rsistence  of  vesical  jjeniorrhoids  wiiich  develo|)e<l  duriiii; 
jtrej^nancy.  Usually  the  blood  disajjpears  from  the  urine  in  a 
lew  days  without  treatment. 

Diseases  of  the  Nervous  System. 
Neuritis  and  Myelitis. 

Neuritis  following  labor  is  due  either  to  (<t)  nerve  injury 
the  result  of  pressure  by  the  child's  head  or  by  forceps;  or  to 
(A)  nerve  disease  the  result  of  se|)tic  infection. 

Neuritis  due  to  injury:  The  injury  to  the  lumbosacral 
plexus  may  be  so  slight  as  to  produce  nothing  but  a  ])artial 
loss  of  power  associated  with  but  slight  pain  or  tendei'iiess  on 
movement,  which  subsides  without  special  treatment  in  a  lew 
(lays.  In  more  severe  cases  the  pain  may  be  intense  an<l  con- 
stant, while  paralysis  and  atroj)hy  of  the  affected  muscles  may 
follow,  being  associated  with  antestliesia.  Pressure  on  the 
sacral  jdexus  by  means  of  the  finger  introduced  into  the  rectum 
gives  rise  to  intense  pain. 

Neuritis  due  to  septic  infection  may  assume  almost  any 
tvpe,  being  multiple,  diffused,  or  isolated,  while  either  motor 
or  sensory  nerves  may  be  affected.  Occasionally  iu  this  form 
the  median  or  ulnar  nerves  may  be  affected. 

Myelitis  is  generally  the  result  of  septic  infection,  though 
Hirst  mentions  having  met  with  a  case  which  ])roved  fatal,  and 
in  which  no  septic  focus  or  apoplexy  could  be  discovered  at  the 
l)()st-mortera. 

Treatment:  In  the  acute  stage  fixation  and  extension  of  the 
part  affected  will  give  the  greatest  relief.  Alternate  iiot  and 
cold  applications,  and  the  administration  of  phenacetin  or,  if 
necessary,  opium,  will  secure  further  relief  from  pain.  Wlien 
this  stage  has  subsided  massage,  electricity,  and  passive  move- 
ment, combined  with  the  administration  of  pot.  iod.  (gr.  x-xv 
t.  i.  d.),  will  hasten  the  restoration  of  the  part  to  usefulness. 

22— Obst. 


liliH        I\\TII<UA)(IY  OF  THE  VUKRPERAL   I'kIHUD. 


Cerebral  Hemorrhage  and  Embolism. 

A  woiiKiM  the  coiKlitioii  of  wlioso  arteries  ])re(lis|)<)ses  licr  fn 
cerebral  hemorrhage  is  iniieh  more  likely  to  be  stricken  with 
tiiis  accident  (lining"  lal)or  tliaii  at  any  other  time.  JIemi|>i(ni;i 
is  not  intre(|Mcnlly  found  to  follow  an  attack  of  celamp>ia. 

Cerebral  embolism  wiien  it  is  not  within  th(!  pnerjxriuni 
j^enerally  follows  an  endocarditis  or  phlebitis  of  septic  origin. 


Puerperal  Insanity. 

Occurrence:  Mental  derantjement  manifests  itself  in  connec- 
tion with  childhearinn;;  most  fre<piently  during  the  puerjXMii! 
period,  rarely  din'ing  lactation,  and  but  exceptionally  during; 
pregnancy. 

The  term  puerpei'al  insanity  is  here  used  to  <lesignate  the  oc- 
currence of  mental  deran<i;ement  at  any  time  l)et>  i'en  the  biiili 
of  the  child  and  the  termination  of  lactation.  ';  he  condition 
is  most  likely  to  occur  in  connccition  with  the  first  confinement, 
thony-h  in  a  small  number  of  <'ases  mental  (leran<rcment  niav 
first  manifest  itself  with  the  second  or  third  partiu'itiou. 

Etiology:  PvcdispoKhu/  cdUHCH :  Jn  many  cases  there  is 
present  a  hereditary  disposition  to  mcMital  derangement.  A 
woman  with  an  unstable  nervous  system  is  manifestly  unsuitcd 
to  bear  the  nervous  strain  incident  to  pregnancy,  j)artiiritioii, 
or  lactation.  Chorea,  ej)ilepsy,  and  hysteria  ])revionsly  exist- 
ing predispose  to  the  development  of  insanity  in  connection 
with  the  ])uerperal  period.  Alcoholism  and  the  narcotic  habit 
shoidd  be  mentioned  as  predisposing  causes. 

Excitintj  on i uses :  Marked  anaemia,  sepsis,  albuminurin. 
eclampsia,  great  physical  or  mental  exhaustion,  and  profound 
emotion  have  been  cited  as  exciting  causes  of  this  condition. 
M('>if(fl  an.vktji  in  connection  with  domestic  worry,  desertioir. 
and  illegitimate  pregnancy  may  be  mentioned  as  an  exciting 
cause. 

Forms :  Two  forms  of  insanity  are  ordinarily  met  with,  the 
mankwal  [\n(\  thin  mrlancholic :  the  former  occurs  much  more 
frequently  during  the  puerperal  period  ;  while  the  latter  is 
generally  associated   with  lactation. 

Puerperal   insanity — symptoms :    In  both  forms  prodromdl 


nisi': ASKS  OF  the  iXervous  system.  339 

ni/)n]itoiiiK  usually  niaiiil'cst  thciusclvi'S.  'I'ljcso  arc  irritahilily, 
restlcssurss,  coiMplaints  oi'  |>(i(y  auuoyanccs,  aud  pci-io'ls  of 
(l('|)r('>si(m,  altcniatinii;  with  conditions  of  nt  rvous  tension.  A 
coutlitiou  of  ucncral  ill-health  is  usuallv  manifested  hv  loss  of 
appetite,  iudip-stion,  const ipatioii,  and  llatulence.  The  patient 
is  usually  pale,  the  pulse  is  irritahle  and  quick,  and  sho  is 
incliueti   to  sudden  outhreaUs  of  tearfulness. 

The  condition  n)ay  dctepen  rapidly,  and  fevci"  develoj),  and 
delusions  aud  halluciualious  heconie  luaiiil'est.  'I'he  lauunaue 
hecoines  ohsccne,  aud  fre(piently  orotiti  niaiiifestations  Ih-coimv 
evident.  The  patient  hecoincs  uucouti'ollahle,  aud  is  vi()lent 
ill  her  actions;  she  may  attempt  to  destroy  her  infant  (»r  attack 
her  attendants. 

In  the  iiirlduc/io/ir  form  the  patient  hecoiues  morose,  de- 
pressed, and  listless;  delusions  of  |)ersecutiou  are  of  frecpieut 
occurrence.  She  accuses  lier  husband  of  inlidelity,  or  ol'  even 
worse  ci'iiucs.  She  hears  voices  tellin<;'  lu;r  to  kill  herself, 
which  she  may  attempt   to  do  iniless  closely   watched. 

In  some  cases  the  jtrodroiiia/  si/iitj)fninfi  may  he  y"  ;(/i(/lif  as 
to  escajx}  ohsi'rvatlon  ;  or  the  condition  may  he  rej^ardcd  as 
one  of  ordinarv  neurasthenia,  when  suddenlv  th<'  ])atient  mav 
attack  and  destroy  her  infant  or  attendant,  or  may  accomplish 
suicide. 

When  a  woman  (hn'ing  the  puerperal  period  manifests  ex- 
cessive irritability  or  unusual  kxpiacity  or  tacitin'uity,  associated 
with  sleeplessness  aud  constipation,  a  close  watch  shoidd  b(» 
kept  on  all  her  actions,  and  she  should  on  no  account  be  left 
alone   \'\th  her  infant. 

Diagnosis:  Usually  this  can  be  made  without  diffieidty. 
i'!ie  d(>lirium  of  mania  must  be  distinotiished  from  that  of 
fever  and  that  of  delirium  tremens. 

Prognosis  :  About  two-thirds  of  all  cases  recover  their  reason 
ill  from  two  to  six  months.  Of  the  other  third,  10  per  cent. 
(lie  of  sej)sis  or  exhaustion,  and  the  balance  remain  i)ernia- 
neiitly  insane. 

^^ania  is  less  likely  to  result  in  permanent  insanity  than  is 
melancholia;  but  it  maybe  said,  that  the  j)atient's  lif(;  is  in 
greater  danger  from  mania  than  from  nudaneholia.  The;  older 
tli(!  j)atient,  the  more  rapid  the  pulse,  and  the  more  persistent 
the  elevation  of  temperature,  the  more  grave  is  the  prognosis. 


.340        PATHOLOGY  OF  THE  PUERPERAL  PERIOD. 

WIkmi  eclampsia  boars  a  causal  relation  to  the  condition  the 
jnognosis  is  distinctly  more  f'avoiable,  for  these  pat'ents  re- 
cover much  quicker  than  in  any  other  variety. 


Treatment  of  Puerperal  Insanity. 

When  possible,  patients  suffering  from  this  affliction  should 
be  removed  to  special  institutions  for  treatment,  and  the  earli(  i 
this  is  done  the  better.  When  this  is  impossible  the  jialii  i  i 
should  be  isolated  with  two  or  three  attendants  who  an 
strangers  to  her.  She  should  never  be  left  for  one  niiiiuif 
alone,  tiie  windows  shoidd  be  securely  fastened,  and  ail  un- 
necessary fui'uiture  removed  from  the  room. 

When  in  mania  it  is  necessary  to  keep  the  patient  in  bed, 
this  may  be  done  by  covc^ring  her  witli  a  strong  sheet  fastenc  d 
at  tlie  sides  and  foot  of  the  bed;  otherwise  instruments  ol 
restraint  should  never  be  employed,  but  a  sufficient  inimlx  r  of 
attendants  should  always  be  at  hand  to  control  the  patient 
if  this  be  necessary. 

The  treatment  otherwise  should  be  largely  symptomatic. 
Nutrition  should  be  promoted  by  every  means  possible,  but 
sedation  shouM   be  avoided. 

It  is  alwavs  well  to  begin  by  securing  a  free  action  of  llx' 
bowels.  This  mav  be  accomi)lished  bv  the  administration  of 
a  mercurial  with  a  subsequent  saline.  The  regular  adminis- 
tration of  intestinal  antise])tics,  as  salicylate  of  sodium  (ir 
naphthalin  (gr.  v  t.  i.  d.),  is  advisable. 

Sleep  may  be  promoted  by  giving  paraldehyde  (.^j-ij)  at 
night.  Instead  of  this,  sulf'onal  or  trional  in  20  grain  doses 
may  be  em])loyed. 

Hydrotherapy  is  of  advantage  both  as  controlling  the  tem- 
perature and  in  securing  sleep. 

The  diet  should  consist  of  milk  in  generous  quantities  at 
first;  later,  eggs  and  meat  may  be  added  as  digestion  im])r<»\('s. 
Stinmlants  should  be  emj)loyed  when  necessary.  ISlalt  ex- 
tracts are  valuable  adjuvants  to  the  diet. 

Forced  feeding  by  means  of  the  oesophageal  tube  may  be 
re(juired  in  rare  instances,  and  it  may  be  replaced  at  intervals 
by  nutrient  enemata. 

Iron  and  arsenic  should  be  given  regularly  in  full  doses,  as 


SUDDEN  DEATH  IN  THE  VUERVERIVM.  841 

soon  as  tlie  condition  of  tlie  digestive  Iract  permits  of  tlieir 
employment. 

As  soon  as  possible  the  patient  shonld  be  kept  constantly  in 
the  open  air  during  tlie  daytime ;  and  exercise  short  of  fatigue 
shonld  be  encouraged. 

The  fact  that  pelvic  conditions  have  nnich  to  do  with  the 
development  of  this  condition  renders  it  necessary  to  make  a 
careful  -jxamination  of  the  state  of  these  organs  in  all  cases. 
All  abnormal  conditions  shonld  be  corrected  as  far  as  possible. 
In  nuuiy  cases  operative  treatment  has  been  followed  by  bril- 
liant results;  but  to  accomplish  this,  such  procedine  should  i)e 
ado})ted  early  in  the  history  of  the  case. 

Sudden  Death  in  the  Puerperium. 

The  most  common  causes  of  sudden  death  in  the  puerperal 
])eriod  are  pulnionarji  emholistn,  cnfrance  of  air  into  the  uterine 
fiinuses,  and  heart-J'aUure. 

Pulmonary  Embolism  and  Thrombosis. 

Etiology:  Some  authorities  claim  that  primary  and  sponta- 
neous coagulation  of  blood  may  take  place  in  the  pulmonary 
artery. 

The  most  generally  accepted  view  is  that  pulmonary  em- 
bolism results  from  the  separation  of  a  }>ortion  of  a  tiirombns 
which  has  formed  in  some  peripheral  vein.  Thrombosis  most 
commonly  takes  place  either  in  an  iliac,  femoral,  or  uterine 
vein. 

Symptoms  and  diagnosis :  This  accident  may  o'^cur  at  any 
time  during  the  earlier  weeks  of  the  puerperal  period.  The 
symptoms  usually  (kn'elop  with  great  suddenness^  and  their 
severity  depends  on  the  size  of  the  embolus.  When  the  ob- 
struction of  the  pulmonary  artery  is  complete,  death  may  be 
practically  instantaneous ;  or  it  may  be  preceded  by  precordial 
<;))pression,  great  dysjmrea,  and  cyanosis.  Usually  the  patient 
utters  a  sharp  cry  ;  the  respirations  become  shallow,  gasping, 
and  irregular,  and  in  a  few  seconds  cease  altogether.  In  cases 
in  which  th(?  embolus  is  small  the  onset  of  symptoms  is  not 
so  sudden  ;  but  they  are  similar,  though  not  so  severe.     Death 


342 


I'ATIIOLOOY  OF  THE  PUERPERAL  PERIOD. 


iiKiy  not  take  place  for  several  days,  and  very  rarely  recovery 
may  follow.  The  symptoms  usually  follow  some  sudden 
UK)vement,  such  as  sitting-  uj),  laughing,  straining  at  stool,  etc 

The  following  may  he  cited  as  an  illustrative  case :  the 
patient,  a  multipara,  had  made  a  perfect  (!onvales(Tence  after  iui 
uneventful  labor,  when  on  the  morning  of  the  thirteenth  day. 
after  being  gently  moved  to  a  sofi  j)laced  alongside  of  her 
bed,  she  suddeidy  gave  a  gasp,  fell  back  on  the  pillows,  and  in 
a  moment  lost  consciousness.  CVanosis  rapidly  developed,  and 
the  resjiirations  became  labored  and  ceased  inside  of  five  min- 
utes. The  ])ulse  at  first  was  rapid  and  strong,  but  (piicklv 
became  thready,  and  ceased  shortly  after  the  fail  •  of  respira- 
tion. 

At  the  (uitopai/  there  were  found  in  certain  of  the  larger 
veins  in  connection  with  the  uterovaginal  plexus  large,  well- 
formed  thrond)i ;  a  thrombus  was  found  to  extend  into  tlic 
right  internal  iliac  vein,  where  it  ended  abruptly  with  a  trun- 
cated and  ap[)arently  broken-otf'  end.  Both  right  and  left 
nulmonarv  arteries  were  found  absolutelv  occluded  with  firm 
red  clot  at  their  very  origin.  Nothing  abnormal  was  found 
elsewhere  in  the  body. 

Treatment :  Usually  death  takes  place  befl^re  any  treatment 
can  be  inaugurated.  In  all  cas(>s  in  which  there  is  evidence  of 
venous  thrombosis  prolonged  and  complete  red  should  be  en- 
joined. From  an  examination  of  the  records  of  four  of  these 
cases  which  came  under  the  observation  of  the  writer,  in  none 
of  which  there  existed  any  evidence  of  thrond)osis  before  the 
onset  of  the  fatal  symptoms,  the  only  abnormal  condition  com- 
mon to  all  was  a  somewhat  increased  pulse-rate.  In  all  four 
the  ])ulse-rate  is  never  recorded  as  being  below  80,  though 
death  took  place  in  each  between  the  tenth  and  the  fifteenth 
days  of  the  ]Mieri)eral  ])eriod.  In  view  of  this  fact  the  writi  r 
is  in  the  habit  of  keeping  all  cases  having  an  unusually  higli 
pulse-rate  as  quiet  as  possible  for  at  least  four  weeks  after  the 
birth  of  the  child,  or  until  the  pulse-rate    becomes  normal. 

In  mi/d  eo.srs  in  which  treatment  is  possible  the  indications 
are  to  keep  up  the  body-temperature  by  the  application  of 
heat  externally,  to  stimulate  the  cardiac  and  respiratory  organs 
by  the  administration  of  ap})roj)riate  remedies,  and  to  secniv 
the  most   absolute  physical  and    mental  rest  for  the  patient. 


FEVER  DUELS  a   THE  PUERPERWM,   ETC.  343 

Entrance  of  Air  into  the  Uterine  Sinuses. 

Causation  :  Tliis  is  ii  very  rare  accident.  Air  may  tiiul 
entrauce  into  the  uterine  sinuses  in  the  course  of  intra-uterine 
manipuhitions,  sucli  as  the  introduction  of  the  hand,  the  givin*; 
of  an  intra-uterine  douclie,  or  by  aspiration  following  a  change 
in  ])Osture  of  the  patient. 

Symptoms:  These  are  practically  tiie  same  as  in  pulmoriary 
embolism. 

Treatment:  This  consists  in  the  hypodermic  administration 
of  stinudants  and  the  employment  of  artificial  respiration. 
Inhalation  of  oxygen  gas,  in  order  to  inflate  the  lungs  and  to 
ex})el  the  air  emboli,  has  been  suggested. 

Fever  during  the  Puerperium  due  to  Other  than  Septic 

Causes. 

Elevation  of  temperature  may  occur  in  the  course  of  the 
puerperal  period  quite  indc})endently  of  t^rptic  hifci-tioii,  from 
such  causes  as  ex|)osure  to  cold,  constipation,  emotion,  or  reHe;^ 
irritation  of  any  kind. 

Emotional  fever:  Profound  ]isychical  im])rcssions,  such  as 
grief,  anger,  fear,  or  even  excessive  joy,  may  give  rise  to  some 
elevation  of  temperature,  especially  when  exj^ericnced  during 
the  early  puerperium.  The  mechanism  of  this  elevation  of' 
temperature  is  not  susceptible  of  explanation  in  the  j)reseiu 
state  of  our  knowledge. 

In  maternity  hos])itals  emotional  fever  is  frccjuently  met  \\'\{\\ 
in  cases  of  iUff/ithiidtc  jtirf^Koicy  about  the  tenth  day  of  the 
puerperium,  as  a  result  of  anxiety  on  the  part  of  such  jiaticnts 
in  regard  to  their  ability  to  j>rovide  for  themselves  and  their 
children  in  the  immediate  future.  In  emotional  fever  the 
temperature  may  rise  to  104°-105°  F.  ;  but  the  cause  being 
usually  transient  the  temperature  quickly  falls  to  normal. 

Exposure  to  cold:  Elevation  of  tem])eratnre  may  follow 
exposure  of  the  breasts  or  abdomen  to  cold  ;  too  low  a  tcm- 
jwrature  in  the  lying-in  room  or  insufficient  bed-clothing  may 
expose  the  patient  to  a  chill,  which  is  usually  followed  by  some 
elevation  of  tem})erature. 

The  administration  of  some  warm  drink  and  the  application 
of  external  heat  usually  cause  the  fever  to  disaj)pear  promptly. 


344       PATHOLOGY  OF  THE  PUERPERAL  PERIOD. 

Constipation:  This  is  a  not  infrequent  cause  of  elevation  of 
temperature  during  the  earlier  part  of  the  puerperiutu.  Tiic 
fever  is  probably  due  to  the  irritation  of  retained  aninml 
alkaloids. 

The  administration  of  a  dose  of  castor  oil  will  probably 
result  in  a  drop  of  the  temperature  to  normal  as  soon  u^ 
the  bowels  have  been  evacuated. 

Fever  from  reflex  irritation  :  The  effect  of  constipation  when 
it  occurs  in  the  puerperium  is  an  example  of  reflex  irritation  of 
the  nervous  system  producing  fever  which  at  other  times  would 
have  no  such  result. 

Irritation  from  engorrjenient  of  the  breasts  frequently  result- 
in  elevation  of  temperature,  as  has  been  mentioned  elsewhere. 

Several  times  we  have  met  with  cases  of  fever  in  which  no 
cause  could  be  found  to  explain  the  condition  until  segments 
of  a  tapeworm  or  a  round  worm  aj)peared  in  the  stools.  Fol- 
lowing the  administration  of  appropriate  remedies  the  worms 
were  expoUed  and  the  temperature  promptly  returned  td 
normal. 

Tympanites :  Tympanites,  or  overdistention  of  the  intestines 
with  gas,  is  not  infrequently  met  with  in  the  earlier  part  of  tin- 
puerperal  period.  This  condition  may  or  may  not  be  attended 
with  fever.  When  this  condition  is  associated  with  elevation 
of  the  temperature  care  must  be  taken  to  distinguish  it  from 
peritonitis. 

Treatment :  Turpentine  enemata  at  short  intervals,  com- 
bined with  the  internal  administration  of  small  doses  of  calo- 
mel, usually  relieve  the  patient. 

Usually  it  is  necessary  to  start  the  treatment  with  an  enema 
of  hot  soap-water  and  turpentine  (^ij  to  Oj).  Then  calomel 
(gr.  Y^jy)  should  be  given  every  hour.  At  the  end  of  six  honrs 
a  dose  of  Epsom  salt  (.iss,  in  two  ounces  of  hot  water)  may  be 
given  ;  and  if  this  is  not  effectual  in  an  hour  an  enema  con- 
taining glycerin  (,lj),  turpentine  (^ij),  ICpsom  salt  (Iss),  and 
water  (.?iij)  should  be  given. 

The  calomel  should  be  kept  up  for  two  days,  and  then 
reduced  to  two  or  three  doses  daily.  As  these  cases  are  due  io 
p:\ralysis  of  the  muscular  coats  of  the  intestine,  a  hypodermic 
of  strychnine  (gr.  ■^^)  should  be  given  every  four  or  six  honi's 
until  the  condition  improves. 


PUEtiPKRAL  Sh'PTIC  IMKCTKiS.  .'M;') 

Puerperal  Septic  Infection. 

The  general  term  puerperal  septic  infection  is  lierc  employed 
to  designate  the  many  and  vaiietl  tliscaMcd  conditions  resulting 
from  infection  of  the  female  genital  tract  during  labor  and  the 
puerperium,  by  microiu-ganisms. 

Frequency:  Previous  to  the  introduction  of  the  antiseptic 
method  of  conducting  labor  the  mortality -rate  from  septic 
infection  varied  between  10  and  15  per  cent,  in  the  large 
maternity  institutions.  As  the  result  of  the  application  of 
rigid  antisej)sis  and  asepsis  to  h(>sj)ital  practice  the  mortality 
from  septic  disease  has  been  reduced  to  a  low  fraction  of  1  per 
cent. 

lu  private  practice  the  beneficial  residts  of  the  antiseptic 
method  are  much  less  marked  than  in  hospital  practice.  Epi- 
demics of  puerperal  infection  are  now  but  rarely  heard  of,  but 
the  mortality-returns  still  show  a  large  proportion  of  deaths 
following  parturition. 

That  septic  conditions  frequently  c()mi)licate  the  puerperium 
is  evidenced  by  the  overcrowded  condition  of  the  gvnjrco- 
logical  clinics  in  all  parts  of  the  country.  A  very  large  pro- 
portion of  these  gynaecological  cases  ]>resent  conditions  which 
owe  their  origin  to  febrile  affections  arising  during  the  puer- 
peral period. 

Bacteriology. 

The  streptococcus  is  the  microorganism  most  frequently 
associated  with  the  occurrence  of  j)uerperal  sepsis.  It  is  to  be 
found  in  nearly  all  fatal  cases. 

The  staphylococcus  aureus  is  the  next  most  freque;  '  cause 
of  puerperal  septic  infection.  Not  infrequently  mixed  infec- 
tions with  streptococci  and  staphylococci  are  encountered. 

The  gonococcus,  bacillus  coli  communis,  bacillus  diphtheriae, 
bacillus  aerogenes  capsulatus,  pneumococcus,  and  bacillus 
typhosus  may  be  mentioned  as  rare  causes  of  puer])eral  sej^tic; 
infection.  These  may  be  found  pure  or  mixed  with  strepto- 
cocci;  M'hen  the  latter  is  the  case  the  infection  is  generally 
exceptionally  virulent. 

T\\Q  gonococcus  ]>lavs  an  inijiortant  part  in  the  production 
of  puerperal  sepsis.     Kronig  has  found  it  to  be  present  in  50 


346        PATJiOLOay  OF  THE  VVKRVKIIAL  PERIOD. 

out  of  179  cases  |)iesonting  febrile  piierperia.  Il  ajjpears  mmi 
ally  to  cause  a  mild  infection,  unless  associated  with  a  streptd 
coccus,  in  which  case  tlie  infection  is  usually  very  virulent. 

Saprsemia:  There  is  a  considerable  class  of  cases  in  Mhicli 
the  symptoms  are  due  to  the  absorj)ti()n  of  toxic  j)ro(lu('ts  pro- 
duced by  organisms  witiiin  the  genital  tract  which  do  not 
make  their  way  into  the  blood-current.  These  are  mostly  ol 
an  anaerobic  nature,  l)elonging  to  the  pufrcfdctivc  class  of 
microorganisms,  of  which  little  is  known.  They  usually  pro- 
duce gas,  and  hence  give  rise  to  frothy,  foul-smelling  di- 
charges. 

Recently  a  great  deal  of  bacteriological  work  has  been  carried 
out  in  the  study  of  the  vaginal  secretion.  Jt  has  been  prac- 
tically })roved  that  the  normal  vagina  in  pregnancy  is  ficc 
from  pathogenic  microorganisms,  at  least  in  its  upper  third. 
The  vaginal  secretions  are  commonly  strongly  acid  in  their 
reaction,  due  to  the  })resence  of  a  so-called  vaginal  bacillus, 
which  in  its  life-processes  j)roduces  lacti(!  acid.  It  is  probably 
this  acid  condition  of  the  vaginal  secretions,  associatetl  with  a 
certain  leukocytosis  due  to  chemotaxic  aetion,  which  results  in 
the  rapid  destruction  of  the  })athogenic  bacteria  shoidd  tluy 
find  entrance  fo  the  vagina. 

It  has  been  proved  that  pathogenic  bacteria  introduced  into 
a  normal  vagina  perish  in  from  eleven  to  twenty  hours  througli 
the  germicidal  action  of  the  normal  secretions.  Preliminary 
antiseptic  vaginal  douches  have  been  ])roved  to  iidiihit  the 
germicidal  action  of  normal  vaginal  secretions.  Pathogoiic 
bacteria  have  been  found  to  flourish  from  eight  to  sixt(<n 
iioiu's  longer  in  the  healthy  vagina  after  antiseptic  douching 
than  when  no  douching  was  employed. 

The  cervix  has  been  usually  found  to  contain  in  its  lowd' 
part  a  few  ])athogenic  bacteria  of  greatly  diminished  virulence 
Its  n])per  part  is  invariably  sterile  in  the  normal  condition. 
The  uterine  cavity  normally  is  entirely  free  from  mici't)organ- 
isms,  both  in  the  pregnant  and  in  the  non-pregnant  condition. 

The  microorganisms  to  be  found  in  the  lower  part  of  the 
vagina  are  usually  non-infectious ;  but  should  pathogenic  bac- 
teria be  present,  their  virulence  is  invariably  greatly  dimin- 
ished as  a  result  of  the  germicidal  action  of  the  normal  secre- 
tions. 


PUERPERAL  SEPTIC  IM'ECTION.  34^ 


Pathology  of  Puerperal  Septic  Infection. 

The  consequences  of  inftrtioii  of  the  jrcnital  tract  of  tlio 
])iier))oral  woman  hy  inicrocM-jraiiisms  are  extrciiicly  variahh'. 
Tlie  infoction  may  he  limited  to  lesions  of  the  vulva  or  va<ji:inal 
outlet,  or  may  ra})iilly  sj)rea(l  fronj  this  locality  to  the  uterine 
cavity.  In  the  most  virulent  cases  no  lesion  may  mark  the 
locality  in  which  the  ^erms  have  eifected  an  entranc(>,  and  yet 
the  patient  may  succumb  with  extreme  rapidity. 

It  is  the  cndometrinm  which  is  affected  in  the  majority  of 
cases  of  puerperal  septic  infection.  This  cndonicfritis  may  be 
septic  or  [ndrid,  according  as  it  is  the  result  of  infection  by 
pyogenic  or  putrefactive  microorganisms. 

The  mildest  form  of  pu('r[)eral  septic  infection  is  the  puer- 
peral ulcer.  These  puerperal  ulcers  are  simply  infected  lacera- 
tions of  the  vaginal  outlet  and  vulva.  Tiny  usually  present  a 
dirty,  greenish-yellow  appearance  and  are  bathed  in  a  purulent 
secretion.  Formerly  these  were  termed  diphtheritic  ulcers,  but 
it  is  very  rare  that  they  result  from  infection  with  the  Klebs- 
Loffler  bacillus. 

Usually  they  cause  but  little  symptomatic  <listurbance,  and 
therefore  their  jiresence  may  pass  unnoticed. 

True  puerperal  vaginitis  may  occur,  but  is  rare ;  it  is  char- 
acterized by  an  inflammation  of  the  vaginal  mucosa,  which 
swells  and  softens,  becoming  bathed  in  a  purident  secretion. 
Lacerations  in  the  vagina  when  infection  occurs  usuallv  become 
covered  with  a  pseudodii)htheritic  membrane.  Rarely,  true 
diphtheritic  vaginitis  may  occur. 

Endometritis:  After  labor  the  more  or  less  lacerated  condi- 
tion of  the  endometrium,  and  the  uneven  placental  site  with 
its  thrombosed  sinuses,  render  the  uterine  cavity  sjieeially  sus- 
ceptible to  the  reception  and  propagation  of  infective  organisms. 
Hence  the  most  common  lesion  associated  \\\{\\  puerperal  septic 
infection  is  endometritis. 

The  infection  may  be  limited  to  the  placental  site;  or  may 
extend  over  the  whole  of  the  endometrium. 

When  the  infection  is  llmital  to  the  placental  .site  the  organ- 
isms develop  in  the  thrombi  in  the  ])lacental  sinuses,  setting  U]) 
a  phlebitis  which  may  be  limited  to  the  uterine  wall,  or  may 


:i4s      I'A'riioLoar  or  tuk  vnuiVKRAi.  vkiiiod. 


extend    to    tin;    surroiiiKliiii;    veins,    and     tliu.s    giv(!    I'iso   \u 
seeondary   injection  elsewhere. 

\\  lien  the  v'liolc  ouloincfriinn  is  involved  the  niiieosa  is  con 
v<'i'te(l    into  a   stinl<ini>;,   necrotic   layer,  which    is   hathcd   in 
bloody  discliar<ije.     The  (piantity  of  necrotic  material  lonii>  ■ 
is  (jitcn  considei'able,  and  it  recurs  vvitli  urcat  ra})idity  ai'lcr  ji 
removal  by  the  curette.     It  consists  of  necrotic  decidual  (lei»r;- 

FlG.  121. 


uterus  from  yiiitient  dyiinrcni  tlic  tenth  tlay  from  iiiiiirc  strt']ito('oecus  iiifcction, 

and    fibrin-exudate    loaded    with   microorganisms    (Figs.    Til 
and   122). 

When  the  infection  is  due  to  the  sfr('ptoco('cii,s  or  to  tlif 
Kf(i/iln(looocci(.'<  the  odor  of  the  lochia  may  not  be  affectid. 
Thus  in  the  most  virulent  cases  the  lochia  may  remain  swict 
throughout;  but  when  the  colon  bacillus  or  any  of  the  jjittn- 


VVEnVKUM  SI'H'TfC  isfectios. 


;mo 


ffir/it'c  (/cniis  arc   |)rt'S('iit    tlic  discliariics  hccoinc  luiil   in  tlic 
(Xiri'iiic. 

Ill  a  lai-<;('   iiiiiiilx'r  ot'  (•a>os  Xatiirc  succeeds  in  liiiiitin<;  the 
iiite(;tive  process  to  the  eii(h»nietriuin,  wliich  it  does  hy  lorniiii^ 

I'Ki.  122. 


tunis  from  patient  dying  on  the  tenth  day  frnni  a  mixed  infection— streptococcus 

and  coluii  bacilli. 


a  l)arrier  or  ohstnictioii  inimediatelv  l)eh)W  the  necrotic  laver. 
I  Ids  barrier  consists  of  a  layer  of  small-cell  infiltration,  desig- 
nated the  zone  of  rcdcfion.  JJeneath  thi.s  zone  the  tissues  are 
u-ually  (|uite  normal. 


;350     I'ATiioLoar  of  tiii':  pukiiperai^  period. 


'riiiis  o)i  sccfioii  \v(!  find  an  internal  layer  consist iiijr  of 
necrotic  dc'cidna  and  HUrin-exudate  swanninjj;  witli  niicro- 
oi'franisnis;  below  this  is  a  layer  of  small-cell  inliltrati(»n,  tli<' 
•'zone  of  reaction,"  containini^  few  if  any  bactei'ia,  while  inidcr 
this  is  the  normal  uterine  tissue. 

Such  is  the  condition  found  when  the  infectittn  is  due  tn 
putrefactive  mi<'roorjj;;anisms,  as  in  jnifrid  ciHlonictrilis,  f^o-vnWvd 
by  IJinmn  and  I)o<lerlein  ;  or  when,  if  du«.'  to  j)yog<".)ic  bacteria. 
thes(!  ar(!  possessed  of  but  little  viridence. 

In  the  so-called  septic  endometritis  (Bunnn  and  Doderlein), 
when  th(;  infective;  organisms  are  virulent  sti'eptocoeci  (u- 
staphylococci,  the  zone  of  small-cell  infiltration  may  be  imt 
imj)erfe(!tly  formed,  or  even  entirely  absent ;  NvhiK;  the  supei - 
ficial  necrotic  layer  may  bo  lacking,  or  if  })resent  be  very  thin. 
In  this  case  the  extension  of  the  infective  process  occurs  bv 
means  of  the  lymphatics,  and  soon  sj)reads  throuii::h  the  uterine 
wall  to  the  peritoneal  layer,  thus  settin<^  up  a  metritis,  lyni- 
phangitis,  and  finally  a  septic  })eritonitis.  This  li/nij)/i<(ti(/ilis 
usuallv  results  in  the  formation  of  numerous  small  absc(ss(>s 
throui^hout  the  uterine  wall,  though  usually  most  marked  Jiisi 
beneath  the  peritoneum. 

Parametritis:  This  inflammation  of  the  oonnootive  tissue 
contiguous  to  the  uterus  frequently  follows  intra-uterine  infec- 
tion tluring  the  j)uerperium.  The  extension  of  the  microorgan- 
isms usually  proceeds  along  the  lymphatics  from  the  endomet- 
rium to  the  peri-uterine  (tonnectiv^e  tissue.  Occasionally  the 
infection  may  originate  in  laceration  of  the  cervix. 

The  infective  inflammation  of  the  peri-uterine  connective 
tissue  produ(!es  extensive  <nlcin(i.  This  niav  result  in  resolu- 
tion, or  in  suj)puration  and  abscess-formation.  When  ex- 
tension of  the  infection  occurs  along  the  lymphatics  in  the 
anterior  portion  of  the  pelvis,  the  inflammatory  (edema  sur- 
rounds the  greater  vessels  of  the  thigh  in  the  neighborhood  of 
the  inguinal  region,  giving  rise  to  one  form  of  jy/i/er/masht  allxt 
(lofois. 

Salpingitis:  The   P\allo})ian  tubes  in  a  certain  nnmlxM'  ot 
cases  become  infected  by  direct  extension  of  the  inflammation 
from  the  uterine  cavity.     Occasionally  the  infection   may  ln' 
carried  to  the  tubes  as  well  as  ovaries,  by  means  of  the  lym- 
phatics. 


PVEliVKHAI.  SEVTIC  ISFFA'TION.  of)! 

Peritonitis:  'I'liis  coiiditioii  iisiimIIv  arises  as  tlic  nsiih  ut'flie 
rapid  rxtciisicdi  of  inrcctiun  iVoiii  tlie  iitcrino  t-avity  by  iiicaii.s 
ol'  tlu!  Iviiipliatics  as  already  descpiht'd. 

Peritonitis  may  rarely  occur  in  consequence  of  [\\v.  rupturi' 
of  a  |)us-tui)e,  or  of  an  ovarian  or  paranief  liiie  abscess.  Septii; 
peritonitis  is  usually  the  direct  cause  of  dealli  in  the  vast  ma- 
jority of  I'atal  cases. 

Pyaemia:  As  already  mentioned,  the  infective  micror»ri:an- 
isms  may  penetrate  the  tlirombi  at  the  placental  site.  'I'his 
rcsidts  in  a  condition  of  septic;  phlebitis,  which  may  bo  limited 
to  tlu!  veins  in  the;  uterine  wall  or  may  extend  to  tlu;  veins  in 
tlu;  neiii'hborhood.  'J'he  t'  rombosis  may  exten<l  as  far  as  tlu; 
inferior  vena  cava.  These  infected  thrombi  may  break  down, 
and  small  [)ortions  may  be  swept  by  the  bloo<l-curreiit  to  dis- 
tant parts  of  th(;  body,  thus  settini»;  uj)  a  condition  of  jna'tnia. 

These  iiifrctrd  cinholi  may  be  deposited  in  the  alxlominal  vis- 
cera, the  liniuK,  th(!  brain,  sj)inal  cord,  the  joints,  oi-  in  the  sub- 
cutaneous tissue  at  any  portion  of  the  body  surface,  where  they 
iiive  rise  to  abscesses.  In  these  cases  there  is  very  little 
involvement  of  the  uterus,  infection  then  beinjjj  limited 
usually  to  the  ])lacental  site.  Death  in  tliese  cases  is  usually 
due  to  exhaustion  foUowintr  a  lonu;  su|)j)urative  process. 

Phlegmasia  alba  dolens:  This  condition  is  known  to  tlu; 
laity  as  "  milk  leg,"  as*  it  was  popidarly  suj^posed  at  one  time 
to  be  due  to  a  metastasis  of  milk.  It  occurs  as  the  residt 
either  of  the  extension  of  a  thrombosis  from  tlie  uterine  veins 
to  those  of  the  lower  extremities,  or  of  a  septi(;  parametritis 
spreading  to  the  eomieetive  tissue  of  the  thigh. 

In  throinhotic  pltlvymaxia  the  swelling  of  the  affected  limb 
usually  begins  about  the  toot,  and  rapidly  extends  to  the  thigh. 

Ill  eelhd'dlc  jdi/cf/masid  the  swelling  begins  in  the  thigh  and 
>preads  down  the  limb. 

in  both  fonn.s  the  ail'ected  limb  becomes  (Miormously  swol- 
Irn.  In  the  first  form  there  is  usually  more  or  less  tenderness 
alou":  the  course  of  the  femoral  vein,  which  is  usuallv  marked 
l)y  a  line  of  inflammatory  redness. 

Modes  of  infection:  The  most  common  mode  of  infection  is 
the  introduction  of  septic  material  into  the  genital  canal,  on 
tiie  h((nds  or  instniniods  of  the  j)hysician  or  midwife  ;  con- 
Ixid  iidh  secretion  from  wounds  of  any  kind,  such  as  infected 


.'352        PATIIOLOdY  OF  THE  PUIAtPKIiAL  PERIOD. 

altiasioiis  on  tlic  hands  of  a  nurse  or  physiciian.     Air-in/evtion 
may  account  lor  a  vci'v  small  proportion  of  casi^s. 

The  iiuffcr  used  to  donclic  the  patient  after  lahor  rimy  carrx 
|)atho<;enie  j;ernis  into  the  ^<'nital  canal.  Conlttct  of  the  vuls.i 
witli  dirty  hed-clothes  or  personal  linen,  or  with  infected  vulvar 
pads,  may  account   for  some  «'ases. 

In  one  case  in  the  untli(tr's  experience  infection  was  pi'ohnliK 
due  to  the  r///7//  liand  of  /he  jMificnt,  who  coidd  not  be  re.'?trainMl 
from  scratclniii:;  the  vulva. 

As  has  been  shown,  tlie  nornml  vagina  is  j)ractically  sterile, 
so  that  when  inl'ecti(»n  occurs  it  is  ^<nerally  the;  I'oult  of  llif 
iiilrodiicdoii  of  jtdf/iof/cnir  iiiddrid/  from  viflioiif.  I'lpidemir-, 
of  sept i(!  injection  have  been  stamped  out  in  maternities  l»\- 
avoiding  all  internal  examinations.  The  best  morbidity  and 
mortality  records  havi;  been  obtained  in  institutions  where 
va<;inal   examinations  have   been  eliminated  as  far  as  possible 

Auto-infection  may  he;  held  to  account  for  a  very  small  jno- 
])ortion  of  cases  of  ])uerperal  sepsis.  In  these  cases  the  patiu- 
genie  ji;erms  are  held  to  Im;  resident  in  the  body,  and  not  i'> 
have  been  introduced  from  without,  during  or  after  laiior. 
The  inicrooriianisms  may  be  lodged  in  the  vagina,  cervix,  nr 
urethra,  as  in  cases  of  gonorrlxea.  Endometritis  antedalinii 
conception  may  accomit  for  the  lodgement  of  germs  in  the 
uterine  mucous  mend)rane,  which  in  the  favorable  conditions 
existing  after  delivery  may  become  virident  and  set  U])  sejitic 
infection.  In  the  same  way  an  old  pus-sae  in  one  of  the 
tubes  may  rnpture  during  labor  and  cause  a  sc})tic  peritonitis. 


Symptomatology. 

The  symptoms  of  septic  infection  may  develop  within  the 
first  twenty-four  hours  after  delivery;  but,  as  a  rule,  nothiiii: 
out  of  the  ordinary  is  to  be  noted  until  the  third  or  fourth  day. 

The  onset  of  infection  may  be  attended  with  a  sen,>-e  of 
malaise  and  j)ossibly  a  slight  headache.  As  the  temperatiiic 
begins  to  rise  the  patient  develops  a  more  or  less  severe  chill. 
which  may  amount  to  an  actual  rigor.  The  tem))eratnre 
(juickly  rises  to  103°  F.  or  higher,  and  the  pidse  beconn- 
very  rapid.  Usually  there  is  only  one  chill,  but  the  temjxin- 
ture  remains  persistently  elevated. 


PLJEltrKllM    SEVTIC  ISlEt'TIoy.  35.'i 

Tli«'  loi'liUt  may  hccoinc  scant,  hiil  as  a  rule  tlic  discliai'^c  in- 
creases in  anionnt.  It  niav  i-einain  Moudv  <>r  niav  rapidiv  he- 
coino  purulent.  In  tli(!  most  virulent  ca>es  and  in  those  due 
to  pun;  Htrentoeoccus  inllrtion,  very  little,  if  any,  odor  is  to  he 
noticed. 

Profuse  fonf-tintclliiif/  locliial  discharge  indicates  a  putrid 
endometritis;  or  a  mixed  infV'ction  due  to  pyogenic  as  wi'l I  as 
putrefactive  orjjjanisms. 

Witli  the  onset  of  en<lometritis  either  of  the  septic  or  the 
j)utrid  form,  involution  of  the  uterus  at  once  ceases,  thus  favor- 
iwf  the  spread  of  the  infection,  in  that  the  lymph-channels, 
hein*^  free  from  compressi(ni,  remain  patent  and  thus  olfer  less 
resistance  to  tlu;  passage  of  micro(>ri;anismH. 

li'  the  infective  |)rocess  extends  beyond  the  uterus,  the 
symptoms  which  then  develoj)  depend  upon  the  tissues  in- 
volved. Symptoms  indicative  of  peritonitis,  parametritis,  or 
pysemia  mjiy  thus  ensue. 

Peritonitis:  The  onset  of  this  complication  is  indicated  by 
the  occurrence  of  intense  pain,  which  is  at  first  limited  to  the 
lower  zone  of  the  abdomen,  hut  "gradually  extends  as  the 
whole-  peritoneum  becomes  alfi^'cted.  As  paralysis  of  the  in- 
testine; takes  place  marked  tympanites  occurs.  In  fatal  cases 
deatli  usually  takes  })laee  within  the  first  ten  days  of  the 
puerperiiim. 

Parametritis:  This  complication,  as  a  rule,  develops  when 
the  endometritis  is  apparently  snbsidinjr.  Its  onset  is  fre- 
([uently  attended  with  a  chill;  the  temjM'rature,  which  has 
probably  fallen,  aj^ain  becomes  ele.ated  and  pursues  a  more  or 
less  irrej^ular  course.  The  extension  of  the  inflammatory  proc- 
ess to  the  parametrium  may  usually  be  detected  by  a  vain;inal 
examination.  The  infiltrated  tissues  surround iuij^  the  uterus 
become  hard  and  tense  to  the  feel.  This  iuHammatioi'  may 
end  in  resolution  or  in  (ihs^ccx.^-foiiiKition — one  lariie  or  several 
small  abscesses  may  form.  The  pus  may  burrow  about  and 
make  its  way  into  the  bladder,  re(!tum,  va*»;ina,  or  peritoneal 
cavity.  Oceasionally  such  an  abscess  may  jioint  at  Poupart's 
liiiament,  or  even  above  the  crest  of  the  iliinn. 

Pyaemia:  In  cases  of  pyjemia  the  initial  symj)toms  of  in- 
flection are  not  so  marked  as  in  the  other  forms.     The  temper- 

23— Obsf. 


3-54        PylTIIOLOGY   OP'  Till':  PU  Eli  VERA  L   PERIOD. 

atiirc  (Iocs  not  rcninin  r<»nst;uitly  clovntcd,  hut  assumes  tlic 
li('(;ti(^  \.y\K\     ( "liills  arc  usually  of  fV((jU('U(  occiUTeMcc, 

Tlio  sul)so(|uc'ut  ,syuij)touis  (Icpoixl  upon  tlic  organs  invadcij 
l)y  the  infected  tlu'oniWi.  Most  coninionly  with  jn'jvinia  we 
liavc  syiuptoHH  of  an  infectious  i)roncliopueunionia  develoj)in^-. 
Tiiis  generally  j)roves  raj>idly  f;.lal. 

In  true  septicasmia,  wliicli  is  tiie  most  viridcnt  form  of  sept ii' 
inlection,  the  organisms  make  theif  way  so  rapidly  into  the 
general  blood-current  tiiat  tiioy  fail  to  become  localized  in  anv 
one  organ.  'I'his  is  the  most  rapidly  fatal  form  of  infection  ; 
death  may  occur  on  the  third  or  foin'th  day  of  the  puerperiinn, 
the  j)oison  being  so  viridcnt  as  to  induce  a  condition  of  [tro- 
foiind  shock. 

Diagnosis  of  Puerperal  Septic  Infection. 

If  on  tlu^  third  or  fourth  day  of  the  puei'peral  period  a 
woman  develops  a  temperature  of  101°  F,,  or  more,  which 
j)ersists  for  twenty-four  hoiu's,  the  condition  present  is  almo>t 
certanily  one  of  septic  infection  pro^'ided  ther<;  is  no  otlior  ap- 
parent cause  to  accoinit  satisfactorily  for  the  symptoms. 

The  most  common  causes  of  an  elevation  of  tcmjx'ratmc 
early  in  the  ])uerperiiim,  not  (ixxociafctl  irith  septic  infection, 
are  :  consti|)ation,  ii-ritation  from  the  breasts,  and  emotional 
excitcmcMit,  fright,  o"  grief.  Malaria  and  typhoid  fever  niav 
complicate  the  puerperiinn,  and  may  be  confounded  with  septic 
infection. 

A  diagnosis  of  malaria  is  only  possible  when  the  ])reseii<(' 
of  tlie  ])lasmodium    lias  been   demonstrated   in  the  blood. 

A  diagnois  of  typhoid  fever  is  not  jiermissible  in  the 
ab-enco  of  ^^  idal's  blood-serum   test. 

l^eforo  making  a  diagnosis  of  septic  infection,  careful,  syste- 
matic physical  examination  of  the  })atient  should  be  made. 

A  careful  examination  of  tiie  characters  of  the  lochial  dis- 
charge may  render  possible  a  diagnosis  of  which  variety  ol' 
endom(>tritis  is  j)resent  in  a  given  ease  of  puerperal  septic  in- 
fection. 

In  all  cases  the  ])hysician  should  make  an  ocular  examination 
of  the  viih'dj  vaf/iud,  and  crrvix  in  a  good  light,  employing  for 
tiiis  purpose  a  larg<!  speculum. 


PUERPKllAL  SEPTIC  JM-JXTloy.  350 

As  it  is  (Ic.-iralvic  to  know  what  organisms  -aw  concenu d  in 
tlie  prodiU'ticMi  of  tiic  inrcctidii,  a  ruffurr  may  be  tak<'ii  iVoin 
the  interior  of  the  uterus.  Tliis  may  l)e  a('('<im|>li>lie(l  with 
hut  little  (iinieulty  \)y  the  method  ree<»mmeii(le(l  Ity  Professor 
W  illiams,  ol"  I>alti(n(»re. 

The  apparatus  necessary  eon>ists  of  a  iila>.s  tuhe,  "20  to  2") 
cm.  in  leUiith  and  .'>  to  A  mm.  in  diameter,  with  a  sliiiht  heiid 
at  one  end  .so  as  to  facilitate  its  intr(.(hiction  into  the  uterus. 
I'his  may  he  stei'ilized  after  j)lacinu'  it  in  a  lonti;  te>t-tuhe  u\' 
thick  glass,  which  contains  in  its  lowci-  exticmity  a  pledget  of 
cotton-wool,  wjiile  its  U})i)er  end  mav  he  closed  hv  a  cotton 
plug  (Figs.   12;}-12o). 

Williams  thus  describes  the  method  to  he  followed  in  oh- 
taining  a  cidture  froe.i  the  uterine  cavity:  "A\'hen  we  wish  to 
make  cultures  from  the  uterus,  our  hands  and  the  external 
genitalia  shoidd  he  thoroughly  disinfected,  the  [)atieut  placed 
in  the  Sims  position,  and  a  sterilized  Sims  or  Simons  speculum 
introduced  so  as  to  retract  the  postei'ior  vaginal  wall  ;  then  the 
cervix  is  caught  with  a  volsellum  forceps  an<l  hrought  down  to 
the  vulva;  the  vaginal  portion  ot"  the  cer\ix  is  then  carefully 
cleansed  with  a  hit  of  sterilized  cotton,  and  the  sterile  lochial 
tuhe  is  removed  from  its  tuhe  and  introduced  into  ic  uterus  as 
liiu'h  up  :is  it  will  go.  care  being  taken  to  avoid  touching  th(! 
external  geiwtals  in  the  o})ei'ation.  To  the  end  of  the  lochial 
tuhe  which  ]>rotrudes  from  the  vulva  a  syringe,  which  draws 
well,  is  attached  by  means  of  a  I'ubber  tube.  Suction  is  made 
whereby  a  certain  amount  of  the  uterine  contents  is  drawn  u|) 
in  the  tube.  The  tube  is  then  withdraw  n  and  its  ends  sealed 
with  .sealing-wax,  when  it  can  be  carried  to  the  laboratory 
without  fear  of  contamination.  On  reaching  the  laboi-atory  it 
i>  broken  in  its  uiiddle  portion  and  cultiu'cs  are  taken  froiu  its 
inntents,  which  we  know  represent  the  uncontaminated  lochia 
iVom  the  u|)jK'r  part  of  the  utei'us." 

When  there  is  iDKlonhfcd  rr/V/rocc  of  <'ndonietritis  the  interior 
Mfthe  uterus  should  be  explored  by  means  of  the  sterile  finger. 
This  procedure  can  be  can'ievl  out  w  lieu  the  culture  has  been 
ehiained.  \W  this  means  important  information  may  be  ob- 
tiiued  which  will  indicate  the  line  of  treatment  to  be  |)Ui'sued. 
\\  hen  the  ira/Zs  of  the  uterine  cavity  are  ro//r///,  the  jti'obability 
is  that  we  have   to  deal  with    \.\  patrcfadive    cmlomdritis ;  or 


35G        PATHOLOGY  OF  THE  PUERPERAL  PERIOD. 


Fig.  124. 


Fig.  123. 


I;  II 


Fig.  125. 


one  due  to  a  pyogenie  organism  of  a  low  degree  of  viruli'iicv. 
When  the  cavity  is  perfeetly  smooth  the  infection  is  probal»ly 
due  to  virulent  .sfrcptococci  or  daphyfococci. 


PUERPERAL  SEPTIC  INFECTION.  357 


Treatment  of  Puerperal  Septic  Infection. 

Prophylaxis:  The  oocurrcnoe  of  puerperal  septic  infeotion  is 
to  be  pr(,'vente(l  by  tlu;  observance  ol'  llie  most  scrupulous 
«.svy).v/.s'  in  the  inetiiod  of  conducting  labor.  This  subject  lias 
been  fully  dealt  with  in  the  section  on  the  management  of 
labor,  to  which  the  reader  is  again  referred. 

Proj>hylactic  (IcicJics  should  not   be  ein[)loyed  except  when 

the  vaginal  secret!  n  presents  marked  evidences  of  abnormality. 

ViKjinal  ('xamm<(ti<msA\o\\\{\  be  made  as  infrecjuently  as  possible 

dui'ing  labor;  in  normal  cases  more  than  one  or  two  are  seldom 

necessary. 

All  vaginal  and  vulvar  lacvrdtions  which  extend  decju'r  than 
the  mu(!osa  should  be  sutured  immediately  after  the  conclusion 
of  labor. 

During  the  first  tico  weeks  of  the  puerperal  j)eriod  the  most 
rigid  asepsis  should  be  observed  in  the  care  of  the  external 
genitals.  The  subject  has  been  discussed  in  this  work  on  the 
section  in  the  management  of  the  puerperium. 


Local  Treatment. 

If  on  examination  of  the  vulva  sloughing  surfaces  are  dis- 
covered, these  should  be  ])ainted  daily  with  tincture  of  iodine. 

When  sutured  wounds  of  the  vaginal  outlet  ])resent  (>vidcnces 
of  infection,  the  stitches  should  be  removed  in  order  to  secure 
free  drainage. 

Endometritis  is  the  condition  most  U'equently  present  in 
puerperal  septic  infection. 

As  previously  mentioned,  the  cavity  of  the  uterus  should  be 
exj)l(  red  and  a  })()rtion  of  the  lochia  removed  for  examination. 

The  method  of  treatment  to  be  followed  will  depend  in  a 
large  measure  on  the  conditions  ])resent  in  the  uterine  cavity. 
The  indications  are  to  remove  all  debris  and  shreds  of  broken- 
down  tissue,  and  to  cleanse  thoroughly  the  interior  of  the  uterus. 
The  routine  use  of  the  curette  in  all  cases  of  puerperal  endo- 
metritis is  mentioned  only  to  be  condennied,  as  in  certain  con- 
ditions this  treatment  may  result  in  the  jn'oduction  of  far  more 
iiarm  than  good. 

When  the  walls  of  the  uterine  cavity  are  found  to  be  perfectly 


358        PATHOLOGY  OF  THE  PUERPERAL  PERIOD. 


smooth  there  is  absolutely  no  iiulication  for  the  em])loyment  of 
the  curette,  as  tliere  is  uothino;  present  that  can  he  reiuoved  l)\ 
it.  Tlie  cavity  siiould  he  douciied  thoroii^idy  with  a  oaljon  (u- 
two  of  hot  yterile  formalin  sohition  (1  :  r>()()j,  alter  which  a  strip 
of  sterilized  iodoform  jiauze,  rolled  so  as  to  foi-m  a  double  wick 
eij>ht  to  ten  inches  long-,  may  be  introduced  as  liiLih  as  the 
fundus.  This  wick  of  gauze  favors  drainage,  and  by  ii> 
jiresence  in  the  cavity  stimulates  the  utci'us  to  conlraet.  Some 
obstetricians  prefer  to  ])a('k  lightly  the  uterus  with  strips  (if 
gauze  after  douching,  but  this  rather  tends  to  interfere  with 
free  drainage,  and  therefore  the  gauze  wiciv  is  to  be  prcfcri'cd. 

If  the  bacteriological  examination  of  the  lochia  reveals  that  the 
infection  is  due  to  .strqtfococci,  further  local  treatment  is  to  lie 
avoided  and  the  gauze  removed  in  forty-eight  hours. 

If  the  interior  of  the  uterus  l)e  foinid  rough  and  jagged,  and 
covered  with  more  or  less  ialse  membrane,  the  walls  of  the 
cavity  should  be  systematically  scrajied  with  a  blunt  cnrcitc 
(Mimde's),  though  many  prefer  the  fingers  for  this  puri»<i,>-c. 
Affrr  cinrffiiir/  the  walls  should  be  explored  by  the  fingei-tijis 
to  make  sure  that  all  debris  has  Ixeu  removed  by  the  curette. 
A  (loucJic  of  hot  formalin  solution  (1  :  500)  may  then  be  (>iii- 
})loved  to  cleanse  the  cavity  thoroughly,  after  which  a  Ijougieor 
two  comj)osed  of  iodoform  (.^ss)  and  suilicient  ol.  theobrom.  to 
make  a  bougie  two  inches  long,  of  the  thickness  of  an  ordinary 
lead-})<Micil,  may  be  intioduced  as  high  as  the  futidus.  TIhh' 
bougies  are  held  in  position  by  the  gauze  wicking,  which  should 
be  introduced  as  reconmieuded  above. 

This  treatment  usually  results  in  a  marked  improvement 
of  the  symptoms,  the  tem])eratiire  falls  within  a  few  liour-. 
and  the  lochia  becomes  mon;  normal  in  type,  h'hoidd  ilic 
temperature  not  yield  to  the  first  injection,  the  tn^atment  may 
be  re})eated  daily,  jirovided  there  is  no  evidence  that  the  in- 
fection has  <'xtended  beyond  the  uterus,  in  which  case  kxal 
treatment  should  be  abandoned. 

Bichloride  of  mercury  solution  should  not  be  eni])loyed  in 
intra-uterine  douches,  as  when  this  salt  comes  in  contact  with 
blood  it  forms  an  innocuous  albuminate.  liumm  has  shown 
that  bich.loridc  injections  ])enetrate  the  tissue  to  only  a  sliglit 
extent.  The  antise])tic  does  not  remain  long  enough  in  contact 
with  the  infected  tissue  to  exert  much  germicidal  action.    I'^r 


PUERPERAL  SEPTIC  INFECTION.  359 

tliis  latter  reason,  and  bocanse  tliu  main  objiHit  of  the  donelio 
i.s  to  wash  away  debris  which  has  been  dotaciied  bv  the  cnrette 
or  finj^er,  many  pret'er  to  empU)y  for  tliis  j)nr|)()so  simple  .sterile 
water  or  salt  solntion. 

Jn  gonococcal  endometritis  it  is  better  to  employ  no  loeal 
treatment,  as  the  majority  of  these  eases  reeover  witiiont  it ; 
or  at  the  worst  are  left  with  a  ehronic  endometritis  whieh  ean 
be  treated  to  better  advantage  later. 

Local  treatment  shonld  not  be  })ersistcd  in  when  it  is  evi- 
dent that  it  fails  to  improve  the  eondition  of  the  patient.  In 
these  eases  all  that  ean  be  done  is  to  dired  our  eH'orts  to  the 
general  improvement  of  the  eondition  of  the  patient. 

General   7)-c(ifnietif. 

These  patients  shonld  rec-eive  all  the  food  they  ean  assimilate. 
The  diet  shonld  consist  ehieHy  of  milk,  eggs,  and  mcat-jniee. 
These  shonld  be  given  in  large  ([nantities,  at  short  intervals, 
and  if  necessary  shonld  be  predigested. 

The  depressant  action  of  the  toxins  shoidd  be  eombatcd  by 
free  stimulation,  and  for  this  pnrpose  onr  most  [)otent  remedies 
are  alcohol  and  strychnine. 

As  mnch  (i/coho/  should  be  given  as  can  be  consumed  with- 
out producing  its  physiological  etfects.  It  is  surprising  what  a 
quantity  of  alcohol  these  patients  can  take  without  a[)parently 
producing  any  untoward  result. 

Stri/c/iuiiK'  should  also  be  given  in  large  d(»ses,  from  JJ^J  to 
■ij\j-  grain  may  l)e  administered  every  three  hours  in  serious 
eases.  Diyitalix  may  be  combined  with  the  strychnine  when 
the  pulse-rate  is  high. 

To  control  the  temperature,  cold  wet  packs  should  be  em- 
ployed, as  well  as  the  ice-cap.  As  a  rule,  antij)yreti(!  drugs 
should  be  avoided  on  account  of  the  depressant  action  tluy 
exert. 

Bumm  has  recommended  the  routine  employment  of  ergot 
in  eases  of  puerperal  endometritis,  in  order  to  secure  better 
contraction,  and  thus  occlude  to  some  degree  the  lymphatics  in 
the  uterine  wall.  Fl.  cxt.  ergotre  (ITl  x)  may  be  given  every  six 
hours,  or  it  may  be  combined  with  (piiniue  (gr.  v)  and  given 
in  a  suitable  mixture. 


360        PATHOLOGY  OF  THE  PUERPERAL  PERIOD. 

The  bowels  should  be  kept  active  by  means  of  a  daily  saline 
whi{;h  acts  f'avoiably  by  draining  the  pelvic  lymphatics. 

The  subcutaneous  injection  of  large  quantities  of  normal 
saline  solution  has  been  employed  in  the  treatment  of  puer- 
peral sepsis  with  marked  beneficial  results.  Jt  is  supposed  to 
act  by  diluting  the  blood,  tlius  favoring  the  expulsion  of  toxic 
matter.  The  saline  solution  may  be  injected  under  the  breasts, 
as  recommended  in  the  treatment  of  hemorrhage;  or  more 
conveniently  into  the  bowel,  in  which  case  at  least  two  quarts 
should  be  given  at  each  injection. 

Recently  it  has  been  suggested  that  nuclein  be  employed  in 
the  treatment  of  these  cases  with  a  view  of  producing  an  arti- 
ficial leucocytosis.  Hirst  considers  that  this  j)lan  of  treatment 
gives  promise  of  practical  results,  and  that  more  is  to  be 
expected  of  it  than  of  serum-therapy. 

Serum-therapy:  When  Marmorek  in  1895  juiblished  the 
results  he  had  obtained  by  the  employment  of  antistrepto- 
coccic serum  in  the  treatment  of  sepsis,  brilliant  results  weir 
expected  to  follow  its  use  in  puerperal  cases.  Recent  statistics 
seem  to  })rove  that  the  results  tl  us  far  obtained  by  the  emplov- 
ment  of  the  serum  are  not  more  favorable  than  those  by  othiM- 
methods  of  treatment. 

As  many  cases  of  puerperal  infection  are  due  to  other  agents 
than  streptococci,  its  routine  employment  in  all  cases  can  only 
be  fraught  with  danger.  When  our  means  of  diagnosis  enables 
us  to  prove  in  a  given  case  that  the  infection  is  due  to  the 
streptococccus  alone,  then  the  serum  should  be  employed,  but 
not  to  the  exclusion  of  other  methods  of  treatment. 

If  care  is  taken  to  make  an  accurate  diagnosis  that  the  infection 
is  due  to  the  streptococcus  alone,  serum-therapy  may  be  em- 
ployed with  fair  certainty  of  success,  especially  if  it  is  used 
early  and  in  large  doses. 

Parametritis :  This  condition  may  be  treated  by  either  hot 
or  cold  applications,  whichever  prove  more  grateful  to  tin' 
patient.  The  ice-bag  will  be  found  to  control  the  extension 
of  the  inflammation  in  many  cases,  while  it  usually  reliev<s 
the  local  pain  to  a  marked  degree.  When  it  is  not  well  borne 
hot  flaxseed  poultices  may  be  applied  to  the  lower  abdonuMi 
and  hot  vaginal  douches  given  at  regular  intervals. 

Probably  most  of  these  cases  heal  by  resolution,  but  a  close 


EPISIOTOMY.  361 

watch  must  be  kept  for  evidences  of  i^iippuiation.  AVhci) 
fluctuation  is  obtained  the  abscess  niav  l)e  opened  tlirouiih  the 
vaginal  vault  v/hen  possible  ;  in  some  cases  it  may  be  neces- 
sary to  make  the  incision  through  the  abdominal   wall. 

Peritonitis:  When  peritonitis  develops  the  treatment  should 
at  first  be  expectant,  in  the  hope  tiiat  the  inflammation  will 
become  localized.  Counterirritation  and  hot  fomentations  to 
the  abdomen,  combined  with  the  free  use  of  saline  cathartics, 
niay  give  good  results.  If  the  symptoms  ])rogress  or  do  not 
abate  within  thirty-six  hours,  then  the  abdomen  may  be  ojK'ued 
and  the  case  treated  according  to  the  conditions  found.  Ab- 
scess, if  found,  should  be  opened  and  drained.  Distended 
tubes  and  ovaries  shouh'  be  removed,  and  under  certain  con- 
ditions it  may  be  necessary  to  perform  hysterectomy. 

The  imilcdtioii.s  for  liyntcn'cUwiy  are  the  ])resence  of  multiple 
abscesses  in  the  uterine  walls ;  and  ])utri(l  endometritis  which 
fails  to  yield  to  rejK'ated  intra-uteriiU!  irrigations  and  curetting. 

Phlegmasia  alba  dolens :  The  patient  should  be  kej)t  in  bed 
with  the  affected  lind)  elevated  so  as  to  favor  the  return  circu- 
lation. The  lind)  should  be  wrap])ed  in  cotton  and  bnndaged 
loosely.  The  rj(H('V(d  trcdiinod  should  be  sup})ortingan(l  stimu- 
lating. 

In  the  cellulinc  variety  fm'pjmraiion  is  very  likely  to  take 
place  in  the  connective  tissue  of  the  thigh.  Abscesses  should 
be  watched  for  and  prom])tly  opened,  so  as  to  avoid  burrowing. 

OBSTETRIC  OPERATIONS. 

Episiotomy. 

Definition:  Episiotomy  is  the  term  ajiplied  to  any  incision 
of  the  external  genitals  to  prevent  extensive  laceration  faking 
place  during  the  passage  of  the  cliild  at  the  time  of  birth. 
The  operation  cannot  be  snid  to  be  in  gen(>ral  use  in  this 
countrv,  but  is  common  in  Germanv  and  Austria. 

Indications  :  These  are  : 

1.  Threatening  central  rupture  of  the  perineum. 

2.  Great  narrowness  of  the  external  genitals. 

3.  Rigidity  of  the  perineum,  especially  when  due  to  cica- 
tricial tissue. 


;J(J2  OBSTETRIC  OPERATIONS. 

4.  Faulty  position  of  the  advancing  part  of  the  Actns  at  the 
onth't. 

5.  ITiidiu!  size  of  the  fo'tal  head. 

Operation:  Tarnicr  lias  rccoMuiicndcd  an  oblicpio  incision 
passing  to  one  or  other  side  of  llic  anns.  Tiie  (ierinans  pil- 
fer lateral  ol)ii((M(!  incisions  directed  toward  tiie  ])osterior  com- 
niissnn!.  It  is  stated  that  such  an  incision  1  cm.  (j^  inch)  in 
lenglii  increases  tiie  circninterenee  of  the  vulvar  orifice  2  em 
{jl   inch). 

The  inxfnininit  used  is  a  l)liint-])ointed  scissors.  During  a 
])ain  one  blade  of  the  open  scissors  is  slipped  sideways  between 
tiie  iiead  and  the  vulva,  and  then  turned  and  the  tissues  cut. 

Tiie  advantage  of  e|)isiotomy  is  the  substitution  (►fa  clean  cut 
of  definite  size,  in  a  i)iaco  where  it  (!an  do  no  harm,  for  an  ir- 
retfuhir  laceration  of  indefinite  size  which  mav  cause  iieniia- 
nent  injury  to  the  patient.  Also  a  clean  incision  is  much  mon; 
easily  sutured  than  a  jagged  laceration. 

IMMEDIATE   REPAIR    OF   VAGINAL   AND    PERINEAL 

LACERATIONS. 

Wliether  the  pelvic  fascia  or  the  fibres  of  the  levator  aiii 
muscles  are  the  all-important  structures  concerned  in  the  suj)port 
of  the  internal  pelvic  structures  is  still  a  matter  of  debate. 
It  is,  however,  certain  that  the  wedge  of  tissue  between  the 
vagina  and  rectum  comjwsing  the  perineal  body  has  practicallv 
nothing  to  do  with  the  sui)port  of  the  j)elvic  contents. 

According  to  Kelly,  the  "real  sujiporting  mechanism  "  nl' 
the  outlet  is  the  (itiferior  portion  of  the  levator  (inl  nvixclc.  Tln' 
more  generally  held  o])inion,  however,  is  that  \\w  pelvic  fttscia 
is  the  supporting  m<M'lianism  of  the  outlet,  and  that  the  sheets 
forming  the  isciiioperineal  layer  of  the  rectovesical  fascia  air 
most  imi)ortant  in  tiiis  connection. 

When  it  is  considered  that  the  vaginal  orifice,  normally  2  to 
8  cm.  in  circumference,  is  dilated  to  3."i  cm.  at  the  moment  ol' 
delivery  to  permit  the  passage  of  an  ordinary  sized  child,  it  is 
not  surprising  that  laceration  commonly  takes  ])lace. 

As  a  matter  of  routine,  after  the  conclusion  of  labor,  tlie 
physician  should  carefully  examine  the  vulva  and  vaginal  ori- 
fice for  lacerations.    This  examination  may  ordinarily  be  made 


liFAWIH  OF  VAGINAL  AND  PERINEAL  LACKliATlONS.   ',W^ 

with  the  patient  in  tiio  dorsal  position,  havinii;  tho  tlii<2;lis 
everted.  A  uood  li<>iit  is  ahsolntelv  iieeessarv.  Wlien  an  ex- 
tenial  superficial  tear  is  found  it  may  be  rej)air('d  at  oiiee,  as 
directed  below. 

Jt",  however,  an  extensive  laceration  should  be  present,  l"urther 
examination  may  be  deiayetl  until  preparations  have  been  com- 
pleted tor  a  repair  o])eration. 

Injuries  to  the  vaginal  outlet  the  result  of  ehildbirth  may  be 
classified  as  follows: 

1.  ivxternal  supei'licial  tear. 

2.  Internal  tear,  or  eond)ined  internal  and  external  tear. 

3.  Complete  tear  of  the  rectovaginal  septum. 


Fk;.  li^G. 


1.  External  Superficial  Tear. 

This  form  of  injury  from  parturition  is  the  most  frequent 
and  also  the  least  important,  as  it  in  no  way  atlects  the  suj)- 
porting    structures    of   the    j)elvic    outlet. 

The  tear  involves  siniply  the  sui)erHcial 
portion  of  tiie  wedge  of  lax  tissue  between 
the  vagina  and  rectum.  It  begins  at  the 
introitus  vaginte  and  extends  backward 
through  the  skin  in  the  median  line;  occa- 
sionally it  may  extend  inward  as  far  as  the 
])osteiMor  column  of  the  vagina  (Fig.  l-li). 
This  laceration  can  be  inspected  through- 
out its  whole  extent  bv  merelv  se|)aratin<r 
the  labia. 

AVhen  the  tear  simply  extends  tliroiif/Ji 
the  foil rcJirffc  strict  cleanliness  until  it  has 
healed  is  all  that  is  re(|uii'ed. 

^\'hen  the  laceration  has  a  base  2-o  cm. 
(^  to  l\  inches)  in  length  it  should  be 
sutured  imnuHliately. 

When  ]):issil)le,  it  is  the  writer's  habit 
to  suture  these  tears  while  waiting  for  the 
detachment  of  the  placenta,  as  the  i)atient 
at  that  time  is  still  more  or  l(>ss  under 
the  influence  of  chloroform.  During  the  slight  operation  the 
uur.se  is  placed  in  charge  of  the  fundus. 


S\ipor(icial  tear  cx- 
tiist'd  by  liiifxiTS  parting 
al)ia  niiiKira. 


304  OBSTETRIC  OPE  It  AT  IONS. 

Instead  of  fijlng  (he  sufiirc.^  at  once,  the  ends  may  l)e  eaiiixln 
in  a  |)air  of  forceps  and  tlie  tying  completed  after  the  dehvc  r\ 
of  the  placenta. 

Necessary  for  the  operation:  A  conple  of  small  cin-ved  iici - 
dies,  a  needle-holder,  three  oi"  four  silkworm-^nt  or  silk  suture-. 
and  a  pair  of  scissors  shoidd  be  sterilized.  Many  jncfcr  tn 
employ  an  Kiniiuii  pcrinvHin-nccdle  in  suturing  these  lacera- 
tions; it  consists  of  a  needle  with  a  large  curve,  niounled  on  a 
handle;  the  needle  is  passed,  threaded,  and  tlu!n  withdrawn. 

The  rule  is  to  place  the  patient  across  the  bed  with  the  but- 
tocks over  the  edge,  the  legs  being  flexed  over  IIh;  backs  of 
two  chairs  properly  arranged.  In  many  cases  it  is  possible  ti- 
suture  these  simple  lacerations  without  disturbing  the  patient 
beyond  sejiarating  and  (,'verting  her  thighs. 

Suturing:  The  })atient  being  j)laced  as  most  convenient,  lli. 
lips  of  the  tear  are  held  aj)art  by  the  fingers  of  the  left  liaii<K 
the  threaded  needle  is  then  introduced  near  the  up|)er  angle  of 
the  wound  about  I  cm.  (1  inch)  from  its  margin,  brought  out 
at  the  floor,  and  reentei'cd,  to  emerge  on  the  skin  snriiice  ojt- 
posite  the  point  of  entrance.  A  similar  sutur(>  is  then  placid 
near  the  lower  angle,  and  both  sutures  tied  after  the  wound 
has  been  cleansed. 

If  the  apjti'oximation  is  not  ([uite  sat  is  fact  oty,  one  oi-  two 
superficial  sutures  may  be  re(|uire(l.  The  end  of  the  siitin-t- 
shoidd  be  left  fairly  long,  so  that  they  may  be  easily  liiuiid 
and  })reventcd  from  causing  the  ])atient  inconvenience  bv 
pricking.     The  sutures  may  be  removed  on  the  eighth  day. 

2.  Internal  Tear,  or  Combined  Internal  and  External 

Tear. 

Conditions :  An  mfcrmtl  tear  when  present  is  found  to  ex- 
tend from  the  fourchette  inward  from  one  to  two  inches,  in- 
volving one  or  both  lateral  sulci  (Fig.  127).  This  tear  alway- 
destroys  the  integrity  of  the  i)clvic  suj)porting  structures,  and 
if  neglected  leads  to  seric^us  residts. 

Such  an  internal  laceration  may  be  present  wiihnut  an  ex- 
ternal wound ;  but  usually  the  external  injury  (already  de- 
scribed) is  to  be  found  afo^oclafefl  irith  the  internal  tear  when 
it  is  present.     On  inspection  a  ragged  bleeding  wound  will  bo 


nEiwin  (tF  vAcisM.  AM)  rimisKM  i.M.'EiiATioys.  )M\r) 

fomid  in  tiie  posterior  vMiiiiml  wall,  associiitcd  probably  with 
iiioi'c  or   loss  external    laeeratioii. 


Method  of  Repair. 


TIk!  |)atieiit  should   be  placed  aeross  the  bed  with  tiic  but- 
tocks over  the  edge,  as  previously  deseribed. 


I'Ki.  l-i7. 


Superficial  combined  iuturniil  and  externiil  tear,  slidwiiig:  portion  of  tear  in  vagina 

that  may  cscain.'  notice. 

The  illumination  of  the  field  of  operation  should  be  the  best 
obtainable. 

Unless  the  patient  is  prej)ared  to  suffer  a  little  pain,  an  an- 
aesthetic, preferably  ether,  should  be  administered.  Thi-ouo;!!- 
out  the  oi)eration  an  assistant  should  guard  the  fundus  uteri  to 
prevent  relaxation. 

The  instruments  recpiired  are  th(>  same  as  before  mentioned, 
with  the  addition  possibly  of  a  couple  of  vaginal  retractoi*s. 


:]«() 


OllSTF/niK'  OI'IHtATIoyS. 


Fi(i.  i'2ri. 


'I'lic  first  step  ill  llic  oiicnitimi  is  to  ascrrfMlii  tlio  mifiirc  mid 
extent  of  the  l;ic(  nilioii.  To  ohtain  a  ii»t<t(l  view,  it  may  Ik 
iicccssarv  to  paciv  tlic  iippcr  part  ol'  I  Ik-  vauiiial  -anal  with 
stcrih;  j:,aiiz(' or  (•ott(»ii  to  prevent  the  flow  ol"  hlood  IVoiii  ahovf 
Ail  raijiicd  and  itadlv  bruised  tissue  ,-hoiild  he  then  ent  away 
and  the  upper  anule  of  the  wound  expond  l>y  means  of  iii< 
finiLJ<'f>  ol'  the   left    hand  or  by  a  retractor  held  hy  an  assi.-taiii 

'The  suturing  sh(»iil(l  eommenee  at   the  upper  anule  (»t"  tli^ 
tear,  and    the  sutures   should   he  ahoiit  a  centimetre  ajiart  ;  a> 
many  shoiihl   l»e  eiiiploye<l   as 
are  re(piired  to  l)rin<;'  theedi^es 
of  the  wound,  or  wounds,  well 
toilet  her. 

The  method  of  inserting  the 
sutures  is  of  very  eoii>ideral»le 
importance,  as  the  oi)ieet  i-  to 
.secure  the  union  of  the  >ii|>- 
))ortinii'striictiii'esol'  tlie  peUic 
floor  ( l-'iu'.  \'2^).  The  needle 
should  he  introduced  on  the 
nnieoiis  surface  ().")  cm.  (  !, 
inch)    from    the    margin    of 


Same  as  Via.  V2~,  with  iiitcTiiiil  sutures 
passed,  ready  to  tie. 


Internal  stitctH>s  tied  ;    external  .stitclics 
in  jiositiun. 


tlie  wound  and  directed  lhroiiL::li  the  tissues  in  the  direction 
of  the  outlet,  bronijlit  out  at  tlie  base,  then  reintrcxlueed,  and 
directed  inward  and  uj)ward  so  as  to  emerixe  on  the  miicoii- 
surface  at  a  point  oi)posite  its  insertion.     Tlius   the  hiop  of 


IlKVMll  OF  VAdlSAL  ASD  ri.IilSF.M  LACEIIATIOSS.   Wiu 
enoh  siitim'  wlu'ii  in  place  is  diicctcd  touaiti  llic  oju  ratof  (l"'iir. 

Kacli  stitiirc  >li(»iil(l  i)('  licil  l(cl'(»rt'  the  next  i-  iiilrodiiccd. 
Till'  last  suture  thus  iutioiliiccd  >li(»ul<l  lniuLi'  tnuciiicr  the 
torn  ('(iy-i'S  of  i-cinaius  ol'  tlic   Iivmh  n  at    llie  \aj:iual  orilicc. 

The  external  wound  may  then  !»•■  r(|iaired  l)\-  a  lew  >uj>er- 
lirial  sutures  introduced  iVoui  the  ,-kiu  >urraee. 


Kiu.  i:;o. 


Conii)li.'te  tiiir,  i!i\(ilviii<r  tlii'  rt'ctoviifriiiiil  sciitmii. 

Dressing:  The  teni])orarv  oauze  tnni]>on  may  then  lie  removed, 
a  vaiiinal  doiiehe  u'iveu.  and  the  wound  dusted  with  an  anti- 
septic powder  hefore  the   vulvar  pad   is  a])|'li((l. 

After-treatment:  The  wound  should  he  l<cpt  well  dust(d 
witli  iodoform  and  boric  acid  powd(M'  (1:7),  constipation 
>liould  be  avoided,  aiul  the  patient  forbidden   to  strain  while 


3G8 


OJiSTJ'JTRlf  OrERATIONS. 


Iiiiviiijj^  a  motion  of  tlio  bowels.  Jf  there  1  c  mueli  tension  oi, 
the  sutiiiv,  eatlicterization  may  be  necessary  in  order  to  relicM 
the  bhuhler.  Tlie  .siitnres  may  be  removed  on  the  eitdith  oi 
tentli  day,  but  the  patient  should  be  kept  in  bed  for  at  leasl 
fourteen  days. 

3.  Complete  Tear. 

Conditions:  A  complete  tear  of  the  perineum  is  one  extend- 
ing; from  the  fourchette  back  .vard  through  the  sphincter  ani, 
and  involving  the  rectovaginal   septum  to  a  greater  or  less 

Fiu   131. 


Complete  tear ;  closing  the  rent  in  the  bowel. 

extent  (Fig.  KIO).  Such  tears  involve  destruction  of  the 
fu'iction  of  the  sphincter  ani  muscle,  and  result  in  inconti- 
nonee  of  faeces  and  flatus.  The  condition  of  the  patien'  thus 
becomes  most  distressinsr. 


Operation. 

Anaesthesia  in  this  instance  is  imperative  for  the  proper  'Per- 
formance of  the  operation. 


REPAIR  OF  VAGINAL  AND  PERINEAL  LACERATIONS.   ;i()9 

Tlie  position  of  the  patient  sliould  be  as  for  tlie  previously 
described  operation,  Tlie  natur;j  and  extent  of  tlie  wound 
sliould  be  first  ascertained  and  the  field  of  operation  thor- 
oughly cleansed. 

The  rectum  is  first  repaired  by  means  of  interrupted  catj>;ut 
sutures  introduced  from  the  nuicous  surface.  The  ends  of  the 
sphinciter  nuist  be  carefully  approximated  by  means  of  buriitd 
catgut  sutures. 

The  vaginal  rent  should  then  be  repaired  as  before  recom- 
mended ;  and,  finally,  the  <s^'//i  surfaces  of  the  perineal  wound 
must  be  brought  together. 

Fig.  132. 


Deep  interrupted  lifting  sutures  in  position. 

It  is  well  to  reinforce  the  catgut  sutures  uniting  the  torn 
ends  of  the  sphincter,  by  means  of  a  large  suture  of  silkworm- 
gut  introduced  on  the  skin  surface  so  as  to  include  in  its  loop 
a  considerabl  »  portion  of  the  nuisde  as  well  as  of  the  septum 
above  it  (Figs.  IP,  1-1:34). 

After-treatment :    CV)nsti[)ation    should    be    avoided,    the 

21     Ob.-c. 


370 


OmTETR  1( '  OPERA  TIONS. 


bowels  being  opened  on  tlie  tliinl  day  and  every  second  dav 
aftonvard.  An  oil  enema  should  be  i^iven  just  before  a  inovi'- 
nient  is  expected,  and  the  edges  of  the  wound  should  be  sup- 
ported by  the  nurse,  the  j)atient  being  warned  not  to  strain 
nor    force    while    evacuation    is    taking    place.     The    wound 


Fio.  133. 


All  snturcR  laid  ;  vnpinnl  sutures  tied. 


Internal  and  external  sutures  tiid. 


should  be  Vv\\^  well  cleMUsed  and  dusted  with  an  antiseptic 
]K)wder.  The  sutures  uiay  be  removed  on  the  tenth  to  the 
twelfth  day.  The  patient  should  remain  in  bed  for  three 
weeks. 


IMMEDIATE   REPAIR    OF    CERVICAL   LACERATIONS. 

Tjaeerations  of  the  cervix  are  rarely  repaired  unless  the  cir- 
cular arterv  is  involved  and  severe  hemorrhajxe  results. 

Cervical  lacerations,  even  when  severe,  fre(juently  heal  by 
first  intention  without  operation. 

Operation:  'i'lie  operation  can  usually  l)e  performed  without 
d'fhculty.     The  patient  is  placed  as  recommended  in  the  \^vv- 


IM)V('TI()S   OF  AliOliTIOX  oTl 

vioiis  operations,  the  eervix  is  seized  with  a  tenaouhim,  drawn 
down,  and  held  in  j)osition  for  sntnrino;. 

The  sntnres  should  be  placed  about  one  inch  apart,  an<l  the 
first  should  be  placed  at  the  upper  angle.  Silkworm-gut 
should  be  employed,  and  the  stitches  may  be  removed  on  the 
twenty-first  day. 

ESTDUCTION  OF  ABORTION. 

Definition:  By  the  induction  of  abortion  is  meant  the  arti- 
ficial emptying  of  the  uterus  before  the  ju'riod  of  viability 
of  the  child  is  reached — that  is,  before  the  end  of  the  twentv- 
eighth  week  of  pregnancy.  Some  authors  limit  the  term 
"  induction  of  aboi-tion  "  to  the  emj)tying  of  the  uterus  before 
the  end  of  the  sixteenth  week,  because  the  methods  of  opera- 
tion ditfer  before  and  after  this  j)eriod. 

Indications:  The  occurrence  of  pathological  conditions  v on- 
sequent  upon  pregnancy,  and  the  aggravation  of  certain  dis- 
eases by  gestation,  give  rise  o(K'asionally  to  the  necessity  of 
emptying  the  uterus  by  artificial  means  at  the  exjiensc  of  the 
child's  life  in  order  to  save  the  woman.  Among  the  con- 
ditions which  may  render  necessary  the  induction  of  abortion 
the  following  may  be  mentioned  : 

1.  II ij pern  lie  si  H  (/ravklarum. 

2.  Rcnnl  iiisufficioirj/,  with  threatened  eclampsia. 

3.  Dentil  of  the  fivtux. 

4.  Insanity,  resulting  from  or  aggravated  by  pregnan(!y. 

5.  Incarceration  of  a  retrofiexed  uterus. 

6.  Presence  of  benign  or  malignant  tumors  which  would 
jireclude  the  delivery  of  a  viable  child  or  render  Ca'sarean 
se(;tion  at  term  inadvisable. 

7.  Acute  hvdramnios  and  cvstic  (le<jeneration  of  the 
chorion. 

8.  Certain  blood  diseases,  as  leucocythiemia  and  pernicious 
auicmia. 

9.  Rarely  hemorrhage  from  ])lacenta  ]>r!evia  may  render 
necessary  the  termination  of  pregnan(n'  befi)re  the  ])ei-iod  of 
tiie  viability  of  the  child  is  reached. 

Tlie  attending  j)hysician  should  considt  with  a  colleague 
luifore  deciding  the  question  of  interference,  and  a  full  ex- 


r. 


372  ORSTKTRW  OPERATIONS. 

pliination  of  tlie  circumstances  of  tlic  case  should  be  made  to 
tlie  members  of  the  family  most  directly  concerned. 

Methods  of  Inducing  Abortion. 

The  administration  of  drugs  internally  for  the  purpose  of 
inducintj:  abortion  is  onlv  mentioned  to  be  condemned.  I'licii 
action  is  slow  and  uncertain,  and  their  use  is  not  infre(|U('nti\ 
attended  with  danjj;er. 

Up  to  the  end  of  the  sixteenth  week  the  quickest  and  most 
certain  method  of  terminating  the  pregnancy  is  the  following  : 

Dilating  the  Cervix  and  Curetting  the  Uterine  Cavity. 

Advantages:  The  operation  can  be  done  in  from  ten  to 
twenty  minutes  ;  it  is  certain  in  effect,  and  when  properly  car- 
ried out  it  is  practically  unattended  with  danger  to  the 
patient. 

Th(;  instruments  required  for  this  operation  are,  a  volselhiin 
forceps,  a  Simon  perineal  retractor,  a  set  of  Hegar's  dilator-, 
a  pair  of  branched  d'lators,  such  as  Goodell's,  an  Emmet 
curette-force])s,  a  sharp  curette,  and  a  pair  of  long  uterine 
dressing-force])s.  Some  strips  of  iodoform  gauze  (10  pci- 
cent.)  for  packing  the  uterine  cavity  and  vagina  should  alsc 
be  prepared. 

Preliminary  to  operation  :  The  patient,  aft(  r  being  anaesthe- 
tized, is  placed  in  the  lithotomy  jmsition  on  a  table  which  is 
in  a  good  light,  the  limbs  being  held  in  position  by  means  ol' 
a  rolled  sheet  or  by  a  crutch.  The  vagina  and  vulva  are  then 
scrubbed  with  s])irits  of  green  soap  and  hot  water,  cotton-wool 
swabs  being  em]>loyGd.  The  parts  are  then  disinfected  1>\ 
niv..;?^^  of  a  douche  of  1  :  500  formalin  solution.  The  hand- 
of  the  operator  an?  then  sterilized. 

The  operation :  The  perineal  retractor  is  placed  in  the  v;i- 
gina,  and  the  anterior  lip  of  the  cervix  seized  with  a  volselhiin 
and  drawn  well  down.  These  instrimients  may  then  be  lieM 
by  an  assistant.  The  cervix  is  then  diUdcd  by  means  •'(' 
Hegar's  and  (4oodell's  dilators  till  it  easily  admits  the  fore- 
finger. The  Ennnet  curctte-forcep'"^  is  then  inserted  into  tlie 
uterine  cavitv  and  the  ovum  seized    tnd   crushed  before  the 


rNDUCTION   OF  PHKMATVRE  LABOR.  ;J7o 

iiistriinu'iit  is  witlidrawii  with  wliatovcr  may  iiavc  lurii 
^raspiMl.  'I'lic  fu'tus  and  as  miicli  of  tlic  rost  ot"  tlio  ovum  as 
is  possihlc  should  ho  removed  hy  these  forceps  ;  after  which 
tile  uterine  walls  should  he  carefullv  and  svstematicallv 
curetted^  hut  without  much  force. 

After  operation:  The  uterine  cavity  is  then  douched  with 
hot  formalin  solution,  and  afterward  packed  with  iodoform 
<>;auze.  Tiie  volsellumand  perineal  retractor  are  then  reiuoved 
and  tlie  operation  is  completed. 

Some  operators  prefer  not  to  empty  the  uterus  at  one  sitting, 
hut  after  removing  the  fietus  to  ])ack  the  cervix  with  gauze 
and  to  tampon  the  vagina  with  antiseptic  wool,  which  are  left 
in  place  for  twenty-four  hours.  On  their  removal,  if  the 
remainder  of  the  ovum  is  not  discharged  I'rom  the  os,  the  cer- 
vix being  softened  hy  the  tampon,  is  further  dilated  and  the 
uterine  cavity  is  thoroughly  curetted  ;  and  is  then  douched 
and  ])acked  with  gauze  as  ahove.  recommended.  This  gauze 
j)acking  should  he  removed  in  from  twenty-four  to  thirty-.six 
hours. 

The  ))atient  should  he  kept  in  bed  from  one  week  to  ten 
days  after  this  operation. 

Abortion,  when  in(hiced  after  the  sixteenth  week  is  accom- 
plished by  means  of  the  methods  to  be  reconnnended  for  the 
induction  of  prcniaturc  labor. 

INDUCTION   OF  PREMATURE   LABOR. 

The  indications  for  the  induction  of  ])remature  labor  are 
much  the  same  as  those  given  for  the  induction  of  abortion. 
In  addition,  however,  may  be  mentioned  (•(mtr<wicd  jtdvcs,  in 
which  it  is  desired  to  avoid  the  necessity  of  C  a'sarean  opera- 
tion or  .symphysiotomy.  Placenta  prscvia,  while  a  rare  indi- 
cation for  abortion,  not  infref(uently  necessitates  the  induction 
of  premature  labor. 

Tt  niav  be  necessarv  to  induce  labor  prematurely  in  ad- 
vanced  heart  disease  and  in  tuberculosis. 


374 


OBSTETRIC  OPERA  TIONS. 


Methods  of  Inducing  Premature  Labor. 

Krause's  method :  This  is  tlio  simplest  and  tlic  most  satis- 
factory in  the  vast  majority  of  cases.  It  consists  in  the  infro- 
(liiction  of  (I  bouf/ic  into  the  nterine  cavity  between  th(!  mem- 
branes and  the  wall  of  the  nterns. 

One  or  two  bout^ies  (No.  10  or  12  English)  are  sterilized  i)v 
soaking  for  an  honr  in  a  cold  solntion  of  formalin  1  loOo. 
The  patient  is  prepared  by  having  the  vulva  and  vngiiia 
washed  and  douched  as  [)reviously  described.  Sjie  is  tiuii 
placed  in  the  dorsal  position  across  the  bed  with  her  feet  (ni 
tw'o  chairs.  The  operator,  after  sterilizing  his  hands,  intro- 
duces two  fingers  of  his  left  hand  into  the  vagina  as  far  as 
the  external  os.  A  bougie  anointed  with  carbolized  vaseliiir 
is  then  guided  along  the  fingers  into  the  cervix  and  pushed 
steaihly  up  until  only  an  inch  or  so  remains  outside  the  ex- 
ternal OS,  care  being  taken  not  to  ruj)ture  the  membranes. 
Sterile  ganze  is  then  i)acked  about  the  butt  of  the  bougie,  to 
keep  it  in  place  and  to  prevent  injury  of  the  jiosterior  vaginal 
wall.  If  at  the  end  of  twenty-four  hours  labor-pains  iiavc 
not  manifested  themselves,  the  gauze  and  bougie  should  be 
removed,  the  v^agina  douched,  and  another  bougie  inserted. 

Tarnier's  method :  This  consists  in  the  dilatation  of  the  cervix 
and  the  introduction  of  dilatable  rubber  bags.  'I'arnier's  l)ag 
is  an  oval  affair,  to  which  is  attached  a  long  rubber  tube  with 
a  stopcock.  The  bag  is  introduced  by  means  of  a  special  toi- 
ce])s,  and  then  dilated  by  pumping  in  sterilized  watei'. 
Barnes's  bags  may  also  be  used  for  this  purjwse,  thougii  the 
best  bag  in  shape  and  material  is  probably  Cham  pet  ier  de 
Ribes'. 

Many  other  methods  have  been  recommended  for  the  induc- 
tion of  premature  labor,  but  the  methods  described  are  practi- 
cally the  most  commonly  emj)loyed. 


FORCEPS. 


History:  It  is  probable  that  the  obstetric  forceps  in  crude 
form  were  employed  before  the  Christian  era.  The  instru- 
ments seem  to  have  fallen  into  disuse  and  were  practically 
unknown  in  the  middle  ages. 


FORCEPS. 


375 


Fui.  135. 


Tlu?  invention  of  tlio  niodcni  instrument  is  wnorallv  end- 
ited  to  one  Poter  ( 'harnhcrlan,  the  son  of  a  I'^rcncli  Ilnuiicnot 
j)liysi('ian,  who  had  settled  in  Kn<j:;hind.  Tlie  ohstetrie  forceps 
remained  a  family  secret  with  the  ( 'hamherlans  for  three  u'en- 
erfttions.  It  was  not  till  172")  that  the  secret  of  the  Chamhcr- 
lan  family  leaked  (»ut  in  England  and  the  obstetric  forcej)s 
became  j)nbli(;  property. 

TJiese  forceps  had  only  the  cepiialic!  cnrve,  which  |)ermitted 
a  tirni  grasp  of  the  head.  Later,  Smellie  in  England  and 
Levret  in  France  improved 
the  force})s  by  adding  a 
second  curve,  whi(^h  adaj)ted 
the  instruments  to  the  curva- 
ture of  the  pelvic  cavity.  The 
viodcriiJ'ojvcjjKiu'v  simply  im- 
proved models  of  those  in- 
vent(!d  by  Smellie  and  Levret. 

Description :  The  obstetric 
forceps  consists  of  two  inter- 
locking branches  or  blades, 
each  of  which  is  provided 
with  a  liandle  to  facilitate 
traction. 

The  /)/a(lefi  are  usually  fen- 
estrated, and  have  a  double 
curve,  a  vcph<ili<\  adapting 
them  to  the  shape  of  the 
fcetal  head,  and  a  jiclric,  ac- 
commodating them  to  the 
sha})e  of  the  ])elvic  canal. 

The  (irik'uldtion  of  the 
blades  is  in  the  form  of  an 
open  lock  in  the  English 
models,  while  the  Conti- 
nental models  generally  have 
the  French  lock,  which  con- 
sists of  a  mortise  and  tenon 


Sinijpson's  Idiin  lorcL-ps. 

screw.     The    English   lock,   having   the    advantage    of  easy 


tightened    bv     means    of    a 


376 


OBSTKTRK '  OVER  A  TIONS. 


adjustnu'iit,  is  to  he  preforrod  to  the  more  coin[)liciit(!(l  uud 
rigid    l^^rciich  lock. 

Tlie  IkokUcx  of  tlie  loreeps  are  usually  serrated  or  grooved 
transversely,  to  give  a  hetter  hold.  In  the  lusttcr  models  the 
handles  are  provided  with  projecting  shoulders  to  facilitate 
traction.  A  (jood  oLsfcfric  forccjhs  should  Ik;  made  of  weil- 
tem|)ered  steel,  polished  and  heavily  nickel-plated  throughout. 
The  edges  of  the  blades  and  the  fenestra  should  he  rounded 
and  smooth.  In  England  and  America  the  favorite  forceps 
is  the  Simi)son-J5arnes.  It  has  the  Barnes  blades  and  the 
Simpson  handles  (Fig.  135). 

The  irriter  has  found  that  for  general  use  the  most  satis- 
factory obstetric  forceps  is  Dr.  Cameron's  model  of  the  Simp- 
son-Barnes instrument.    Dr.  Cameron  has  modified  the  pelvic 

Fiu.  136. 


Cameron's  model  of  Simpson-Burnt's  forceps.' 

curve  of  the  blades  in  such  a  maimer  as  to  permit  a  nnicli 
more  secure  grasp  of  the  fietal  head  being  obtained  than  i- 
the  case  in  other  models  (Fig.  136). 

For  low  operations  a  simple,  light  instrument,  such  as 
Sawyer's,  is  very  useful. 

In  high  operations  the  line  of  traction  must  correspond  as 

'  J.  H.  Chapiuan,  Montreal. 


FORCErS. 


377 


niiich  ;is  possible  to  tlic  axis  of  the  jx'lvic  inlet.  In  sucli 
oj)(.'nitioiis  a  j^rcat  amount  of  traction  force  is  lost  hecausc  it  is 
impossible  t<>  ^<'t  the  handles  of  tlu.'  ordinary  forceps  hack  far 
enonjrh  on  aceonnt  of  resistance  offered  hy  the  perinenm 
This  diflieulty  has  been  overcome  by  the  invention  of  the 
(ixis-iradioii  forceps  by   Tariiier,   iu    1877   (I'ig.    Vil).     By 

Fio.  137. 


Tarnier's  axis-traction  forceps. 


means  of  traction  rods  attached  to  the  base  of  each  blade, 
tittinoi;  at  their  lower  ends  into  a  sj)ecially  curved  ))erin<'al 
bar,  to  which  is  attached  a  cross-bar  as  a  handle,  the  line  of 
the  traction  force  is  brou<j!;ht  into  relationship  with  the  axis 
of  the  brim.  The  Tarnier  forceps  is  so  constructed  that 
when  the  lower  ends  of  the  traction  rods  are  held  1  cm.  from 
the  shanks  the  line  of  the  pull  will  be  in  the  axis  of  the  birth- 
canal  no  matter  what  the  position  of  the  blades  may  be  in  the 
pelvis. 

Many  other  modeh  of  axis-traction  forceps  have  been  in- 
vented, but  none  has  proved  so  generally  satisfactory  as  the 
Tarnier. 


378 


OliSTETRW  OVER  A  TIONS. 


Indications  for  the  Use  of  Forceps. 

Ill  general  terms  it  may  Ix'  stated  tliat  tlu-  iailuro  of  a 
woman  to  dcliviT  licrsclf,  when  delay  in  delivery  will  en- 
danger tlie  life  of  the  mother  or  tlu;  child,  or  hotli,  is  an  indi- 
cation for  the  employment  of  foreej)s  to  terminate  labor. 

Anomalies  of  the  meehanism  of  lahor  resulting  in  failure 
of  the  ju'esentino;  part  to  advance  have  been  fully  (liseii>M(l 
in  detail. 

Other  indications :  Insnnieient  expulsive  power,  as  nteriiu 
inertia  from  whatever  cause ;  increased  resistance  in  the  pil- 
vio  canal  from  moderate  pelvic  contraction  or  from  unusu;il 
ri'i'idity  of  the  soft  structures;  over-size  or  undue  ossilieiitioii 
of  the  fcetal  head  ;  ahnormal  presentations  or  positions  of  the 
fetal  head,  as  lime  presentation  and  occipitoposterior  position.-; 
(Ku-idnifdf  rondidoxN,  such  as  eclampsia,  placenta  pra'via,  pro- 
lapse of  the  funis  or  of  a  fu'tal  member. 

Exhaustion  of  the  mother  is  evidenced  by  a  steady  increase 
in  the  raj)idity  of  the  pulse-rate,  rising  temperature,  and  a 
proirressivc  failure  in  the  force  of  the  uterine  contractions. 

Danger  to  the  child  is  indicated  by  the  fetal  heart  beats 
becoming  rapid  and  weak  or  slow  and  feeble. 

If  in  the  course  of  the  second  sfaf/c  of  labor  the  head  fails 
to  advance,  and,  either  because  of  feeble  contractions  or  from 
increased  resistance,  is  arrested  for  half  an  hour,  the  labor 
should  be  terminated  by  forceps. 

When  forcej)s  are  indicated  the  following  conditions  must 
be  present  to  render  the  application  of  the  blades  permissible : 

1.  The  OS  must  be  com])letely  dilated  or  easily  dilatable; 

2.  The  membranes  must  be  ruptured  ; 

3.  The  child  must  be  livinji;  and  viable; 

4.  The  head  must  be  engaged  in  the  brim  ;  or  it  must 
be  ]>ossible  to  crowd  the  head  down  to  the  pelvic  inlet  by 
external  j>rcssure; 

5.  The  head  must  be  of  average  size  and  consistence,  or 
else  the  blades  will  not  retain  their  hold  ; 

6.  The  relative  ])roportion  between  the  head  and  the  pelvis 
must  be  such  as  to  make  extraction  possible  with  safety  to 
mother  and  to  child  ; 

7.  The  position  of  the  head  must  be  favorable  ;  for  instance, 


FOnCEPS.  .']79 

it  is  prnctically  iinjMtssiblc  to  cleli'cra  inciitoposltiior  pusitioii 
of  tiic  i'ace. 


Preparation  for  the  Forceps  Operation. 

Instruments,  etc. :  Tlic  oljstctric  forceps,  as  nvcII  as  siicli  iii- 
stniinciits  and  siilinH's  as  may  Ix'  rcfjiiircd  (or  llic  rcjtaii'  of 
lacerations  snl>sc(|nent  to  delivery,  siionld  he  \vi-:i|t|)ed  in  a 
clean  towel  and  boiled  for  ten  ininntes,  aftei*  \vlii(li  tliey  niav 
be  placed  in  a  basin  containini::  cold  sterile  water,  to  cool  «ili'. 

Preparation  of  the  patient:  The  h/<uhlrr  n\u\  nchiiii  slionld 
be  eni|)tie(l  ;  after  wliicli  the  abdomen,  tliiuhs,  and  external 
genitals  shonld  he  rendered  as  aseptic  as  j)o>sihle.  If  there 
be  reason  to  susjx'ct  contamination  of  the  r<i(/iii(i,  the  intei'nal 
passages  shonld  l)e  thoroughly  scrnbhed  and  donched  as  for  a 
sjirgical  operation.  The  Inbricity  ol"  the  parts  may  then  be 
restored  by  the  application  of  sterilized  glycerin  or  vaseline. 

When  tlie  operation  has  to  be  done  with  the  patient  in  hal, 
a  Kelly  j)ad  or  rubber  sheet  should  be  ai'ianged  under  the 
jtaticnt's  hips  so  as  to  conduct  all  discharges  into  a  baby's 
bath-tub  or  other  vessel  on  the  Hoor.  The  j>«//V/(/'.s'  (imhs 
should  then  be  Mrapped  about  with  freshly  laundried  or  ster- 
ilized sheets. 

The  operator's  hands  and  forearms  should  be  sterilized,  and 
he  should  wear  either  a  sterilized  apron  or  a  sheet,  to  protect 
his  clothing. 

Preliminary  to  operation:  The  t)perator  should  then  sit 
down  facing  the  genitals  of  his  patient,  ("lose  to  his  hand 
should  be  ])laced  his  instruments  and  a  basin  containing  a 
weak  formalin  solution  (1  :  1000),  as  avcH  as  some  ])ieces  of 
sterilized  gauze  or  a  ])lentiful  suj)ply  of  clean  towels. 

Before  proceeding  to  apply  the  force])s  the  (juality  and 
fre(piency  (;f  the  faidl  hearf-heafs  should  be  ascertained  aiul 
an  exact  knowledge  of  the  poxiilon  and  vJtardcier  of  the  jOial 
Jirad  obtained.  For  this  latter  it  may  be  necessary  to  j)ass 
the  entire  hand  into  the  uterus;  hence  the  ])atient  sliould  be 
anjesthetized  before  making  this  examination.  Any  mal- 
])osition  of  the  head  should  then  be  altered  if  j)ossible  before 
the  application  of  the  blades  is  attem])ted. 

Anaesthesia :   It  is  rarely  possible  to  employ  the  obstetric 


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380  OBSTM'Rrc  OPKIiATfOXS. 

forceps  satisfactorily  unless  tiic  patient  is  under  liie  iuHuencc 
of  an  an:estlietic.  For  j)rolon^^e(l  or  dilTiiMilt  cases  ether 
should  he  used  in  preference  to  chloroform,  and  its  adminis- 
tration entrusted  to  a  medical  assistant. 

Posture  of  the  Patient. 

The  application  of  the  obstetric  forceps  is  possible  with  the 
patient  cither  in  the  dorsal  or  in  the  left  lateral  position. 
Many  consider  that  the  application  of  the  forceps  is  more 
difficult  in  the  left  lateral  than  in  the  dorsal  position  ;  but 
this  difficulty  is  more  appa'v-nt  than   real 

Generally  speakin*^,  the  lateral  position  o  .  s  many  advan- 
tages, especially  if  tli(;  oj)erator  lacks  a  skilled  assistant.  In 
this  position  the  patient's  limbs  do  not  re(iuire  to  be  sup- 
ported. Tiie  application  of  both  blades  is  accomplished  with 
the  right  hand,  while  the  Hngers  of  the  left  hand  places! 
within  the  vai^ina  serve  to  j^uidci  both  th*'  blades  into  position. 
During  traction  the  perineum  is  undcjr  constant  observation, 
and  extraction  is  easier  and  safer. 

Walcher's  position:  On  account  of  the  increased  mobility 
of  the  sacro-iliac  joints  in  the  latter  months  of  ])regnan('y  a 
certain  limited  amount  of  rotation  of  the  sacrimi  is  possibh 
on  a  transverse  axis  passing  throiigii  its  second  vertebra. 

After  experiments  with  the  live  subject  and  with  the 
cadaver,  Walcher  demonstrated  that  by  placing  the  woman  at 
full  term  on  a  table  in  the  dorsal  position  with  the  buttocks 
close  to  its  edge,  and  the  lower  limbs  hanging  unmipporfcd. 
the  coniuffate  diameter  is  len<>:thened  bv  from  one  half  to 
one  centinHitro.  This  posture  of  the  patient  is  known  as 
Walcher's  position.  The  posture  may  be  utilized  to  advan- 
tage ill  high  forceps  operations  or  in  difficult  versions. 

The  Forceps  Operation. 

There  are  two  methods  of  aj)plication  of  the  forceps.  That 
known  as  the  Knglhli  mrfliod  is  to  apply  the  blades  so  as  to 
correspond  to  the  sides  of  the  pelvis,  (juite  regardless  of  the 
position  of  the  head. 

The  Continental  method  is  to  apply  the  blades  to  the  sides 
of  the  child's  head  regardless  of  the  pelvis. 


FORCEPS.  381 

The  |>olvi(^  application  of  tlio  blades — /.  r.,  tlie  Enjxlish 
method — is  on  tiie  whole  safer  and  l)etter,  as  less  (hunaii;e  is 
possible  to  the  niattrnal  soft  parts. 

The  eej)halie  aj)j)lieation  of  the  blades — /.  f.,  the  Continental 
method — shonld  oidy  bo  emj)loye(l  by  experienced  and  expert 
operators,  as  it  is  the  more  complicated  and  ditficnlt. 

The  o])cration  is  divided  into  the  A////*,  the  iiioliinn,  and  the 
/orr,  acu'ording  to  the  position  of  the  head  in  the  pelvis. 

In  the  hifj^h  o|)eration  the  head  is  arrested  at  or  Just  eniiajjcd 
in  the  pelvic  brim.  In  the  iiiedhuii  oj)eration  the  head  is 
arrested  well  within  the  pelvic  cavity.  In  the  /o/r  operation 
the  head  rests  npon  the  pelvic  floor. 

In  high  operations  the  axis-traction  forceps  should  be  em- 
ployed, and  the  i)atient  shoidd  be  j)laced  in  W'alcher's  j)osition 
until  the  h"ad  has  been  drawn  down  into  the  |)elvic  cavity. 
As  a  rule,  it  is  more  convenient  for  the  operator  and  better 
for  the  ])atient  if  she  be  placed  on  a  table  for  the  high  forceps 
o|)e  ration. 

fn  medium  and  low  operations  the  patient  may  be  j)laced 
either  in  the  left  lateral  or  in  the  dorsal  position,  whichever 
is  more  convenient  for  the  operator. 

Forceps  Operation  in  the  Dorsal  Position. 

The  )>atient  havinc;  been  ])re})ared  for  the  o|)eration,  is 
placed  in  the  dorsal  ])osition,  across  the  bed  with  the  buttocks 
projecting  slightly  over  the  edge. 

Support  of  the  limbs  :  When  assistants  are  not  obtainable  to 
hold  the  limbs,  they  may  be  supported  as  in  the  lithotomy 
position  by  means  of  a  rolled  sheet  passed  under  the  neck 
and  over  one  shoulder,  having  the  end"  fastened  at  the 
patient's  knees. 

A  better  metJwd  is  to  ])lacc  two  ordinary  wooden  chairs  a 
short  distance  apart  with  their  backs  to  the  edge  of  the  be<l. 
The  jiatient's  knees  ar(»  then  flexed  over  the  backs  of  the 
chairs,  folded  towels  being  so  i)laced  as  to  protect  the  pop- 
liteal regions  from  injiny.  The  operator  sits  facing  the 
patient. 

Introduction  of  the  blades :  Having  made  an  internal  ex- 
amination and  having  satisfied  himself  as  to  the  exact  position 


382  OBSTETRIC  OPERATIONS. 

of  tho  fcofal  lioad,  tlio  operator  sehicts  the  Icff,  or  /oir<-r,  bUidc 
of  the  forceps,  whieli  lie  grasps  elose  to  the  shaft  with  the 
fingers  of  tlu;  left  liamly  hohlinj^  the  instrument  as  lie  would  a 
pen.  Two  or  more  fin<:;ers  of  the  ri(/ht  hand  are  inserted 
within  the  vagina,  and  if  possible,  within  the  eervix,  their 
))alinar  surfaces  being  in  eontaet  with  the  child's  head.  The 
tingers  are  carried  as  high  as  it  is  possible  to  introduce  them, 
and  the  maternal  soft  parts  held  outward  away  from  the  head. 

The  left  hlfide  i,s  then  held  j)i'rjicn<li(.'ul<(r/i/  to  the  woman's 
body,  and  the  tip  is  guided  along  the  fingers  of  the  right 
hand  within  the  vulva.  No  force  is  required  to  introduce 
the  blade,  which  is  guided  along  the  fingers  of  the  internal 
liand,  by  slowly  swee|)ing  the  handle  downward  along  the 
internal  surface  of  the  mother's  left  thigh.  This  blade  when 
in  })osition  rests  between  the  head  and  the  left  lateral  wall  of 
the  pelvis. 

The  upi>vi'  bliidc  is  then  held  in  the  right  hand  in  similar 
fashion,  and  is  guided  along  the  fingers  of  the  left  hand 
within  the  vagina,  the  handle  being  de])ressed  along  the 
mother's  right  thigh. 

The  forceps  are  then  locked  by  depressing  the  handles 
toward  the  ])erineum  and  gently  rotating  the  bhules  into  i)osi- 
tion.  Care  should  be  taken  not  to  include  hair  or  a  portion 
of  the  vulva  in  the  bite  of  the  lock.  In  guiding  the  blades 
into  position  it  is  important  to  have  the  fingers  of  the  internal 
hand  introduced  as  far  as  possible  and  t(»  press  the  maternal 
tissues  well  to  one  side. 

After  locking  the  forceps  a  careful  internal  examination 
should  be  made  to  ascertain  if  a  good  grasp  of  the  head  ha,-; 
been  obtained,  and  that  nothing  but  the  head  has  been  in- 
cluded in  the  bite  of  the  forceps.  The  luindla^  are  fJieii 
(/fdsjjed  near  the  lock  with  one  hand,  the  fingers  being  hooked 
over  the  projecting  shoulders  while  the  back  of  the  hand  is 
directed  upward. 

Extraction  is  effected  by  steady  jmlling,  or,  better,  by  exert- 
ing a  slight  pendulum  movement  at  the  same  time. 

The  line  of  traction  should  corres])ond  to  the  axis  of  the 
plane  of  the  pelvis  in  which  the  head  is  engaged  ;  thus  in  hif/h 
operatinna  the  line  of  traction  is  directly  backward  to  cor- 
respond to  the  axis  of  the  brim  ;  in  medium  operations  tlie 


FOR<  'EPS.  ;is;] 

line  of  traction  is  directly  liorizontal  ;  wliilc  in  /air  oprrafious 
it  is  npwanl,  so  tliat  tiie  handle's  are  directed  toward  the 
mother's  abdomen. 

The  tractions  shoidd  be  intermittent,  like  tlic  natural  pains. 
A  ^ood  rule  is  U)  pull  for  oiw  minute  and  then  to  rest  for 
two.  nurinji^  the  intervals  it  is  better  to  inifocl:  f/ir  forcrjis, 
so  as  to  relieve  the  head  from  pressure  and  also  to  favor  its 
rotation  as  it  descends. 

Traction,  when  once  the  perineum  begins  to  distend,  nnist  be 
made  very  carefully  in  order  to  avoid  the  sudden  descent  of 
the  head. 

The  line  of  trdcfion  should  be  pretty  nuich  horizontal  until 
the  occiput  pivota  under  the  pubic  arch.  After  this  has 
occurred  no  fnrther  traction  \a  necessary,  l)Ut  the  head  is  slowly 
and  carefully  extended  by  pushini^  the  luuulles  upward  in  the 
direction  of  the  mother's  abdomen. 

When  the  licdd  can  he  retained  iti  f/ie  perineitm  by  pressure 
aj){)lied  from  behind  in  the  (^occyneal  reji'ion,  the  forceps  may 
be  gentlv  removed  and  tin;  head  delivered  without  them.  The 
liead  in  lield  in  position  bv  i^raspinir  it  throuji;h  the  perineum 
with  the  left  hand.  On  no  a(?(!ount  should  the  lingers  be 
inserted  into  the  anus  for  this  piu'pose,  as  it  is  unnecessary 
and  dant^erous  to  do  so. 

When  the  head  can  he  lielu  in  ])osifion  the  blades  may  be 
removed  in  the  reverse  order  of  their  application.  The  utmost 
gen'  Mioss  should  be  employed  in  their  removal,  and  no  force 
should  be  exerted  if  anv  obstach*  be  encountered.  A\'hen 
gentle  manipulation  fails  to  release  a  blade,  it  should  be  left  in 
place  until  the  head  is  delivered. 

After  the  forceps  have  b^en  removed  the  iiead  can  be 
delivered  by  pressure  over  the  perineum. 

As  a  general  rule,  forceps  o])erations  are  performed  with 
excessive  speed,  hence  the  frequency  of  lacerations  of  the 
maternal  soft  j)arts  following  their  employment. 

Axis  Traction. 

Tn  high  operations  axis-traction  forcaps  should  be  used, 
though  a  certain  degree  of  axis  traction  may  be  obtained  witii 
the  ordinary  forceps;  as  will  be  described  later. 


384 


OliSTKTRK '  OPERA  TIONS. 


The  patient  having  hec^n  j)lac'e(l  on  a  table  in  the  dorsal 
position,  with  the  buttoeks  at  the  <'(!<:;e  and  the  limbs  held  by 
assistants,  or  supported  by  ehairs,  the  blades  are  inserted  in 
the  ordinary  manner  with  the  traetion-bars  fastened  ( Fi^. 
138).     After  insertion  the  blades  are  loeked,  and,  if  Tarnier's 


Fu:.  138. 


Guiding-hand  and  forceps  blade ;  high  application.     (Farabocuf  and  Varnier.) 

instrumc  it  is  used,  the  lock-pin  is  screwed  moderately  tiaht. 
The  bar  conneeting-  the  handles  is  then  thrown  across,  locked, 
and  the  screw  tightened  nntil  the  blades  have  secured  a  firm 
but  not  too  tight  grasp  of  the  foptal  head.  The  lower  ends  of 
the  traction-bars  under  the  shanks  are  then  loosened  and 
the  perineal  handle  adjusted  to  them  and  locked. 


FORCEPS. 


;»8r> 


After  riHcortainlng  tnat  a  jn'opor  jj^rip  of  tlio  luad  lias  hrcn 
obtained  and  that  the  various  screws  are  properly  adjusted 
without  the  inclusion  of  portions  of  vulvar  tissue  the  patient 
can  be  placed  in  the  Walcher  position  hy  reniovintji;  the  sup- 
ports from  her  linihs.  J^y  plaeinj^  large  Mocks  or  hooUs 
under    the   table-legs  nearer   the    o})erator  the   table  can   be 

Fig.  13y. 


^^fft'-'^^^Wff-^' 


Traction  with  axis-traction  fnrcci>s. 

inclined  in  such  a  manner  that  the  buttocks  will  \vA  be  ])ulled 
too  far  over  the  edge  when  traction  is  exerted.  'I'lic  line  of 
traction  should  be  downward  and  backward  as  far  as  possible, 
the  traction-rods  being  kej)t  about  a  (piarter  of  an  inch  from 
the  shanks  throughout  the  pull  (Fig.  l.'^Ol 

Between    the   tractions,    the   connecting-bar    between    tlie 

25  -01)St. 


.">86  OnsTETIUa  OPERA  TIONS. 

Imndlcs  should  he  unscrewed  and  tlic  piii-l()(!k  loosened  in 
order  to  relieve  the  fu'tal   head  iVoni  continued   pressure 

When  the  head  has  been  drawn  down  to  the  pelvic  floor 
there  is  no  further  need  either  for  ti'.e  W'alclier  position  or 
for  the  axis-tra(!tion  rods.  The  patient  may  then  he  placed  in 
the  ordinary  position,  the  p(!rineal  handle  may  he  removed, 
and  the  traction-rods  fastened  in  their  places  heneath  tlic 
Idades,  the  force|)s  then  heinj;;  used  as  the  ordinai'v  instru- 
UK^nt.  Some  operators  prefer  to  remove  the  Tarnier  instru- 
ment as  soon  as  tlu;  head  reaches  the  [xdvic  floor,  completinjr 
the  delivery  by  means  of  Sawyer's  small  forceps. 

In  hii^h  operations  a  certain  amount  of  axis  traction  can  he 
exerted  with  the  ordinary  long  forceps.  By  l*aoet's  or 
(lalal)in's  manoMivre  the  line  of  traction  can  Ixj  broiii^ht  to 
correspond  fairly  well   with  the  axis  of  the  pelvic  inlet. 

Tiuis  hy  pressinj^  or  pullini^  downward  with  one  hand 
])laced  as  near  the  shanks  as  invssihle,  and  by  pressini;  or 
pulling  u])ward  with  the  other  h.and  on  the  handles,  two 
forces  are  brought  into  action,  with  the  elfect  that  tlu,' 
resultant  acts  in  the  line  of  descent  of  the  head.  The  forcei)s 
by  this  manoeuvre  is  used  as  a  lever,  the  hand  grasj)ing  the 
siianks  beinijj  the  fultM'um. 

In  em])loying  this  man(JMivre  the  greatest  care  must  be 
exerci.sed  to  prevent  the   blades  slip})ing. 

Forceps  Operation  in  the  Left  Lateral  Position. 

The  patient  is  placed  somewhat  obliquely  across  the  bed, 
lying  on  her  left  side  with  her  thighs  well  flexed,  the  hips 
being  brought  well  over  the  right  edge  of  the  bed.  A  folded 
pillow  may  be  placed  between  her  kriees  to  keej)  the  thighs 
separated.     The  oj)erator    sits  facing  the   ])atient's  buttocks. 

The  preparations  for  the  ojieration  are  otherwise  the  same 
as  mentioned  in  dealing  with  the  application  of  forceps  in  the 
dorsal  position. 

Insertion  of  the  blades:  Two  fingers  of  the  operator's  left 
hand  are  inserted  along  the  posterior  wall  of  the  vagina, 
through  the  cervix  when  possible  and  well  over  the  present- 
ing ])art,  pivoting  the  finger-tij)s  upon  the  head  globe,  while 
the  cervix,  the  posterior  vaginal  wall,  and  the  perineum  arc 
pressed  back  as  far  as  possible  out  of  the  way. 


/•'OAv  •i:rs. 


;;h7 


The  loircv  hhnlc  hciii^^  licld  in  the  ri^iit  lunxl  witli  tlic 
pelvic  curve  directed  hackward,  so  that  tlie  tip  of  the  instni- 
nient  is  in  contact  with  the  left  hand,  is  thus  introduced 
within  the  vajrina.  To  facilitate  tlic  intro(hiction  of  tiie  tip  of 
tlie  bhide  in  this  j)osition,  the  liandii'  must  he  held  h>\v  down, 
correspond i no;  to  tiie  direction  of  the  ^hiteal  fold  of  the 
patient's  left  buttock  (  Fiir.  IKM.  As  soon  as  the  //y>  of  tiio 
blade  has  been  guided  by  the  lingers  of  tiie  left  hand  over  the 

Fig.  140. 


Position  of  imtiont  for  forceps  delivery  und   mode  of  introducing  lower  blade. 

(I'liiylair.) 


convexity  of  the  head  the  InnxJ/c  is  raised,  Ix'ing  swept  up- 
ward over  the  mother's  right  thigli,  and  Hnally  l)ackwar(l  and 
downward,  until  the  shank  falls  behind  the  operator's  left 
wrist.  The  handle  thus  sweeps  through  nearly  three-cpiarters 
of  a  circle  as  the  blade  is  being  introduced  and  pushed  up. 
This  movement  of  the  handle  causes  the  tip  of  the  blade  to 
sweep  around  and  under  the  head. 

The  fi)i(/('rs  of  flic  left  luiml  remain  in  contact  with  the  head 
throughout  the  insertion  of  both  bhules,  the  first  blade  being 


388 


OBSTETRIC  OPERA  TIOXS. 


held  ill  j)<)sliioii  aftor  its  introduction  by  rostiiip^  ap;ainst  tlio 
back  of  llu;  left  wrist  wliilc  the  second  is  hcing  nianii)nlatc(l 
into  ])osition. 

TIk-  iiji/xr  hhulc  is  then  j,n-asjK'd  in  the  rigiit  hand  and  its 
tip  intnxhiced  into  the  vulva  above  the  shank  of  the  first 
blade  with  the  pelvic  curv(!  directed  forward.  The  i'n^  is 
guided  into  position  over  the  convexity  of  the  head  by  the 
fingers  of  the  left  hand  (Fig.  141).     The  handle  is  then  swept 

Fig.  141. 


Introduction  of  the  upper  blade.    (Tlayfair.) 

do'/nward  and  backwan^  cdong  the  mother's  left  thigh,  thus 
causing  the  blade  to  move  around  the  iippn'  surface  of  the 
head   to   take  its  position   opposite  the  right  ilium. 

The  second  blade,  having  been  placed  in  position,  is  used 
as  a  guide  in  locking  the  handles.  It  is  held  steady  while 
the  first  blade,  which  may  become  displaced  during  the  intro- 
duction of  the  second,  is  manceuvred  into  position  so  as  to 
lock  (Fig.  142). 

Extraction:  After  examination  to  .see  that  all  is  secure,  the 
operator,  grasping  the  hauvlles  over  the  projecting  shoulders 


FORCKPS. 


:wii 


witli  liis  rijrlit  haiul,  exerts  traction  as  far  l)a<'k\vanl  as  pos- 
sihle,  at  tlic  same  time  stea<lyin«»;  the  patient's  liips  witii  his 
left  liaiid.  Diiriiii:;  extraction  in  tiie  lateral  jjosition  the 
handles  describe  a  lu)riz()ntal  are  from  left    to  ri<,dit. 

Fig.  142. 


Forceps  in  position.    Traction  in  the  axis  of  the  brim,  downward  and  backward. 

(I'liiyl'air.) 

When  the  head  can  he  retained  in  the  distended  perineum 
the  forceps  may  he  gently  removed  and  tlie  delivery  com- 
pleted withont  them. 

Forceps  in  Persistent  Occipitoposterior  Cases. 

Ordinarily,  wlien  it  is  necessary  to  terminate  labor  by  means 
of  the  forceps  in  posterior  positions  of  the  ()eeij)nt,  if  the  Iir(((l 
id  well  flexed  before  the  instruments  are  apj)lied,  and  if  the 
blades  arc  diseju^ajjed  com|)letely  by  nnlo('kin<»;  them  after 
each  tractive  effort,  the  occiput  will  be  brought  in  contact 
with  the  pelvic  floor  first,  and  will  thus  rotate  to  the  front 
without  special  difficulty. 


390  OliSTETRW  OVEliATIONii. 

Wlicii  rotation  forward  of  the  occiput  fails  U\  tnkc  plucc 
plenty  of  time  should  he  givi'U  for  [>r«)j)er  moii/ditif/  ol'  the 
lieiul  to  <  'cur. 

'Die  normal  nieehauisin  of  deliverv  in  face  to  puhes  cases 
must  be  home  in  mind,  and  the  forceps  so  used  as  (o  aid 
iiatuH!.  Tiic  line  of  traction  should  he  in  the  axis  of  the  pel- 
vic cavity — that  is,  hori/ontally — until  tiie  forehead  emerges 
sutticiently  for  the  glabella  to  pivot  r.nder  the  pubic  arch  ; 
tlu!  iian(l'>s  are  then  I'aised  so  as  to  bring  the  o(!ciput  over  the 
perineum,  after  whi(;ii  tlu;  face  generally  dtilivcis  itseif  by 
cxtfMision  of  the  head. 

()n(!e  the  (jUihiihi  /i<i,s  j)irof((l  nii^ny  operators  [)refer  to 
remove  the  blades  and  deliver  the  head  manually. 

Forceps  in  Face  Presentations. 

In  posterior  positions  of  the  chin  in  face  presentations  the 
forceps  arc  contraindicated. 

In  mento-anterior  positions,  when  nature's  efforts  are  insuf- 
ficient to  complete  delivery,  the  force])s  may  be  emj)loyed. 
The  blades  should  be  applied  to  the  sides  of  the  child's  head 
in  such  a  way  as  to  secure  a  firm  gras|  f  the  occiput.  Trac- 
tion  should  be  made  hnrhontdlhi  until  the  chin  is  brought 
i.nder  the  pubic  arch  ;  then  by  raising  the  handles  and  with- 
out pulling,  the  head  is  flexed,  thus  sweeping  the  face,  vertex, 
and  oceij)ut  successively  over  the  ])erineum.  This  inovcmoif 
of  flexion  should  be  made  with  great  deliberation,  and  when 
laceration  of  the  perineum  takes  place  and  threatens  to  extend 
into  the  rectum  a  hitcral  iiici.slnn  should  be  made  in  order  to 
avoid  this  troublesome  complication. 

Forceps  in  Breech  Cases. 

Indications :  AVhen  in  breech  cases  it  is  impossible  to  reach 
a  foot  or  to  employ  a  fillet  or  the  finger  to  draw  down  the 
presenting  part,  the  fon^eps  may  be  used.  AVhen  possible, 
the  axis-traction  forceps  should  be  employed  for  this  pur)>ose. 

The  grasp  of  the  breech  may  be  obtained  by  placing  the 
tip  of  the  blades  over  each  trochanter  and  below  the  iliac 
crests.     When  this  hold  cannot  be  obtained,  the  blades  may 


1)0  iiifrixliicod  so  tliat  one  is  in  (MtntiU't  with  tlio  sju'rum 
Mild  OIK!  iliiiin  of  llie  child,  wiiih-  the  other  is  in  <'oiit:ict 
with  lh»'  posterior  surface  of  the  ()])j)ositc  thi^h,  as  recom- 
meiuh'd   i>y  Oiiivier. 

'J'lie  after-coming  head  lias  occasionally  to  he  delivei-ed  hy 
forceps  al'tei-  the  failure  of  other  methods.  'I'he  application 
of  the  hiades  is  not  dillicidt,  j»rovi<led  the  child's  hody  is 
liold  iij)  over  tlu;  ahdonicn  of  the  incttlier  by  an  assistant. 

The  Dangers  of  Forceps  Operations. 

Tl»e  forceps  itidicionslv  and  skilfully  nse<l  should  seldom 
result  in  the  j)roduction  ol'  serious  ii'jurv  to  either  mother  or 
child. 

W'.icn  forcej)s  o))erations  are  nndertak<'n  hy  unskilled 
operators  and  in  unsuitahle  cases  the  most  disastrous  conse- 
(juences  may  follow  :  the  uterus  has  been  perforated  hy  the 
tips  of  the  blades ;  the  cervix  and  lower  uterine  se«iinent 
have  been  torn  away  ;  the  pelvic;  joints  have  been  sprun»j; 
ajtart  ;  while  most  extensive  vaginal  lacerations  are  not  in- 
fre(|Uent,  as  the  residt  of  im|)ropei'ly  performed  fort;eps 
opei'ations.  The  most  common  injui'ics  are:  lacerations,  more 
or  less  extensive,  of  the  perincmn  and  vagina,  and  certain  in- 
juries of  the  child's  head  the  result  of  compression  of  the 
blades.  ( 'ontiisionsand  abrasions  of  the  face  or  scalp  are  not  in- 
frccpient,  and  occasionally  facial  paralysis  may  follow  pressure 
upon  facial  nerve-trimks,  Intra(!ranial  hemorrhages  arc;  not 
infre(pient  afu^r  forceps  o])erations.  Such  hemoi-rhage  may 
result  in  rapid  death  ol'  the  newborn  child,  or,  if  siu'vived, 
may  ^ive  rise  tt»  idiocy,  hemiplegia,  epile})sy,  etc.  Occasion- 
ally the  cord  may  be  aroimd  the  child's  neck,,  and  be  so  ex- 
posed to  pressure  from  the  tip  of  the  blades  that  fatal 
asphyxia  may  ensue. 

VERSIONS. 

Definition:  The  p;oneral  term  rrrftion  is  applied  to  such  ob- 
stetric o|)erations  as  are  desij2;ned  to  bring  about  any  alt(  - 
tion  in  the  relation  of  the  long  axis  of  the  child's  head  to  the 
long  axis  of  the  uterus. 

Varieties :  There  are  three  varieties  of  versions  : 


392  OnSTKTIilC  OrKRATIONS. 

Ccpludic,  resulting  in  prosontation  of  tlie  head  ; 

Pelvic,  of  tlu!  breech  ;  juid 

Podtr/iCf  of  one  or  botli  feet. 

Methods  :  There  are  three  methods  of  perform iii<i^  version  : 

External  ver,sio)i,  which  is  accomplished  by  manijjiihition 
throngli  the  ab(U)men  ; 

BipoUir  verfiion,  aecomplislied  by  external  and  internal 
manipuhi'ions  combined  ; 

Ititcnud  rcrfiion,  accomplished  by  the  introduction  of  the 
hand  within  the  uterus. 

External  Version. 

By  means  of  external  version  either  the  head  or  the  breech 
can  be  made  to  present  at  the  pelvic  brim.  It  is  probably 
the  simplest  and  safest  method  of  turning,  as  there  is  prac- 
tically no  danger  connected  with  it. 

The  more  ])ractised  the  operator  i-;  in  abdominal  palpation 
of  the  pregnant  uterus  the  more  skilful  will  he  prove  in  the 
performance  of  external  version. 

Indications:  The  most  common  indication  for  external 
version  is  breech  |)resentation,  when  diagnosed  during  the 
latter  weeks  of  pregnancy.  While  the  indications  for  this 
form  of  version  are  in  general  the  same  as  those  that  apply 
to  the  other  forms,  the  fact  that  it  can  be  emj)loyed  only  he- 
fore  or  very  early  in  labor  limits  its  availability. 

Conditions  for  external  version :  The  membranes  should  be 
intact  or  but  recently  ruptured.  The  uterine  and  abdominal 
walls  should  be  lax  and  the  child  freely  movable.  These 
conditions  are  only  present  before  the  onset  of  labor  or  very 
early  in  its  course,  hence  to  these  periods  the  operation  is 
limited. 

Preparations:  The  bladder  and  rectum  should  be  emptied. 
The  patient  should  be  in  the  dorsal  decubitus,  with  her  thighs 
slightly  flexed  and  the  head  and  shoulders  sup])orted  by  ])il- 
lows.  The  abdomen  should  be  exposed  or  covered  only  by  a 
sheet,  under  which  the  bands  of  the  operator  are  placed.  An 
anaesthetic  is  not  required  unless  the  j)atient  is  extremely 
nerv^ous. 


VERSIONS  ;3{)o 


Method  of  Operation. 

Tho  first  duty  of  the  operator  is  (!:iref'iilly  to  iniip  out  tlie 
position  oeoiipied  by  tlie  child.  This  is  done  hy  palpation, 
sup])letnented  by  aiiseultation  of  the  f<etal  heart. 

He  should  then  plot  out  the  nianeonvre  he  wishes  to  aeeoin- 
jdish  from  beginning  to  end,  before  attempting  to  displace  in 
any  way  the  f(etns. 

In  pertbrming  external  version  the  most  important  point  is 
to  keep  the  fietal  ovoid  intact  throuf^^hout  the  o)>eration. 

The  manoeuvres:  '^J'he  operator  ])laces  a  hand  on  each  end 
of  the  fir'tal  ovoid,  with  the  palms  facing  and  the  fingers  of 
one  hand  dire(!ted  toward  the  wrist  of  the  other.  \^\  the 
alternate  fiexion  of  the  fingers  of  either  hand  the  version  i^ 
accomplished.  One  hand  gives  a  movement  of  ascent  and 
the  other  a  movement  of  descent,  each  acting  alternately. 

The  extremity  of  the  fa»tal  ovoid  it  is  desired  to  bring 
down  is  made  to  follow  the  shortest  route  which  will  bring  it 
into  proper  relationshij)  witii  the  |)clvic  brim.  Should  uterine 
contraction  occur  during  the  mani|>ulations,  the  o|)eraior  must 
be  content  to  hold  the  fVetus  in  the  ])osition  gained  until  re- 
laxation occurs,  when  the  operation  may  be  proceeded  with. 

AVhen  the  fcetus  has  been  placed  in  the  desired  position  a 
vaginal  examination  should  be  made  to  ascertain  whether  the 
presenting  part  is  ])ro]ierly  over  the  iidct. 

To  irfain  flicfa'fii.s  in  ))osition  until  the  presenting  part  lias 
engaged,  longitudinal  pads  comvtosed  of  folded  towels,  may  be 
placed  on  either  side  of  the  fetus  and  a  fii'm  abdominal 
binder  apj^lied. 

Occasionally,  when  external  version  has  been  carried  out 
after  the  onset  of  labor,  it  is  advisable  to  rupture  the  mem- 
branes, so  as  to  favor  the  retention  of  the  fu'tus  in  its  new 
position. 

Bipolar  Version. 

The  chief  advantage  of  the  bipolar  method  is  that  complete 
dilatation  of  the  cervix  is  unneeessarv,  as  bv  this  metho<l  ver- 
sion  can  be  aeeom])lished  as  soon  as  two  jlncjevH  can  be  in.scrfcd 
through  the  os  uteri. 

Bipolar  version  has  the  disadvantage  that  it  fails  to  give 


394  OBSTETRIC  OPERA  TIONS. 

tlie  opomtor  s\\v\\  (control  of  the  fct'tiis  as  is  obtainable  by  tlie 
internal   nuttliod. 

Tliis  form  of  version  is  also  known  as  the  Braxton-Hicks 
method. 

Indications:  Phiccntd  praria  with  bnt  partial  dilatation  of 
the  OS  is  given  by  most  text-books  as  the  ehief  in(li(!ation  foi- 
selection  of  this  method  of  })ei'forming  version. 

Ill  the  experience  of  the  writer,  the  very  fact  that  the  pla- 
(;enta  is  sitnated  in  the  lower  uterine  segment  coiifrdiNflicnfis 
the  employment  of  this  method,  as,  with  only  two  fingers 
through  the  os,  the  presenting  part  cannot  be  satisfactorily 
reached  ;  for  the  pelvic  inli't  is  occu])ied  more  or  Jess  by  the 
bulky  placenta.  For  this  reason  in  placenta  ])ra^via,  when 
version  is  desirable,  the  internal  method  should  be  selected 
and  the  OS  dilated  until  the  whole  hand  can  be  introduced  into 
the  uterus. 

Oflicr  i>idic<(fio)i.'<  for  this  method  are  :  abnormal  j>resenta- 
tions  or  ])ositions  of  the  head,  such  as  face  or  brow  presenta- 
tions and  prolapse  of  the  cord,  when  diagnosed  early  in  labor. 
It  is  also  very  useful  in  transverse  cases,  whether  it  is  desired 
to  bring  down  the  breech  or  the  head. 

Conditions  for  bipolar  version:  The  membranes  should  be 
intact  or  so  recently  ruj)tured  that  the  child  is  still  freely 
movable.  The  cervix  should  admit  two  tingers,  and  the 
vagina  be  capable  of  containing  the  operator's  hand  if  neces- 
sary.    The  uterine  and  abdominal  walls  should  be  lax. 

Preparation:  'J'he  patient  should  l)e  ])repared  as  for  a  for- 
ceps operation.  She  should  be  placed  in  the  dorsal  position, 
across  the  bed,  witli  her  hips  at  the  edge,  the  legs  being  suj)- 
]K)rted  by  chairs.  The  operator  sits  between  the  ])atient's 
thighs,  after  having  well  sterilized  his  hands  and  forearms. 
The  external  hand  can  be  kept  from  contamination  by  wra[)- 
])ing  it  in  a  sterilized  towel. 

Anaesthesia  is  desirable,  but  not  necessary,  provided  th(> 
vagina  and  vulva  are  lax  and  the  patient  not  nervous. 

Method  of  operation :  Before  proceedivg  in  operate,  the 
diagnosis  of  the  position  of  the  fietus  should  l)e  confirmed  by 
careful  external  and  internal  examination.  The  details  of 
each  movement  of  the  operation  should  then  be  })lanned  so 


il 


VERSIONS.  :]9r) 

that  the  operator  has  clearly  in  mind  exactly  wiuit  he  wishes 
to  accuniplish  by  his  nianceuvres. 

In  head  preacnUitionn,  in  which  it  is  desired  to  bring  down 
the  breech,  the  head  shonld  be  moved  in  the  direction  in 
which  the  occipnt  points. 

The  fingers  of  the  hand,  the  palm  of  which  points  in  the 
direction  in  which  it  is  desired  to  move  the  presenting  part, 
are  then  introdnced  through  the  cervix.  Thus,  if  j)resentati</U 
is  L.  O.  A.  and  it  is  desired  to  bring  down  the  breech,  two 
.  fingers  of  the  la&iuuMl  are  introduced  within  the  cervix,  wiiile  n<-V>i-^ 
/  '  tiie  a^lrt  hand  presses  down  the  breech,  through  the  abdominal  fr^y.JL 
wall.  The  version  is  accomplished  by  a  series  of  alternate 
pushes  with  either  hand.  Vaxyh  should  be  taken  not  to  rupture 
the  membranes,  should  they  be  intact,  until  a  foot  or  leg  is 
within  reach  of  the  internal  fingers  at  tiie  pelvic  brim. 

In  correcting  an  abnormal  presentation  of  tlie  head  by 
combined  manipulation  the  fingers  of  the  internal  han<l  push 
the  lowest  part  of  the  fcetal  head  upward  and  backward  while 
the  external  hand,  having  located  the  occiput  through  the  ab- 
dominal wall,  endeavors  to  force  the  vertex  downward  and 
forward  within  the  pelvic  brim. 

In  such  cases,  if  the  membranes  have  not  ru}>tured,  th(\v 
should  be  broken  as  soon  as  the  position  of  the  head  is  altered. 
Pressure  should  then  be  maintained  upon  the  fundus  until  the 
vertex  has  become  firmly  engaged  in  the  brim. 

Internal  Version. 

This  method  of  version  is  most  commonly  employed,  as  it 
is  probably  the  most  rapid  and  effectual  way  of  securing 
delivery  when  the  head  is  not  engaged  in  the  pelvic  brim.  It 
is  the  most  dangerous  method  of  version,  as  the  hand  must  be 
placed  into  the  uterine  cavity  in  order  to  seize  one  or  both 
feet. 

Indications :  Eclampsia,  placenta  prjevia,  threatened  sud- 
den maternal  death,  prolapse  of  the  cord,  and  accidental 
hemorrhage  may  be  mentioned  as  indications  for  this  method 
of  version,  especially  when  rapid  delivery  is  desired. 

Other  indications  are  transverse  presentations,  moderate 
pelvic  contraction,  prolapse  of  fietal  members,  and  rupture 
of  the  uterus. 


396  onSTETRW  OPKBATIONH. 

Conditions  for  internal  version  :  Tlio  crrvix  must  l)o  dilatcc!, 
or  <lilatal)U( ;  the  [X'lvis  must  be  .siitTicieiitly  am[)lo  to  j)enuit 
the  [)assa<^(!  of  tlic  after-coiMiu^  licad,  and  the  iitcnis  must  not 
l)e  t(!tanically  coiitraotod  .iboiit  the  child.  Tlie  condition  of 
tlic  lower  uterine  .se<;ment  sliouhl  he  ascertained  before  version 
is  attempted,  and  tlie  pc/sition  of  tlie  retraction-ring  noted,  if 
it  be  present.  The  foetus  must  not  be  impacted  in  tlie  pelvis, 
but  should  be  sufficiently  movable  to  permit  the  presontint;^ 
part  to  be  pushed  back.     The  child  should  be  viable. 

Preparations:  When  possible  the  patient  should  be  j)lace(l 
on  a  tiible  for  operation.  Prei)arations  should  be  made  as  for 
a  force])s  ()j)eration.  The  vagina  should  be  scrubbed  an<l 
rendered  antise[)tic,  being  afterward  smeared  with  sterilized 
glycerin  or  oil.  The  most  useful  antiseptic;  for  such  cases  is 
lysol  or  creolin,  as  these  substances  have  lubricating  cjualities 
and  render  the  em{)loyment  of  glycerin  or  oil  unnecessary. 

It  is  well  to  have  at  hand  some  sterilizetl  bandage-material 
or  broad  tape,  in  case  it  may  be  necessary  to  pass  «  noose 
about  the  f<etal  limbs,  to  facilitate  extraction.  The  })atient 
should  be  anicsthetizcd,  and  for  this  ])urj)ose  chloroform  is 
usjially  recommended  as  bringing  about  better  uterine  relaxa- 
tion than  ether.  It  is  desiral)le  that  the  anaesthetic  should  be 
administered  by  a  medical  assistant. 

Th(  natient  should  be  placed  m  the  lithotomy  position  with 
her  hip  it  the  e<lge  of  the  bed  or  table.  The  operator,  with 
his  hands  and  arms  sterilized  and  his  clothing  })rotected  by  an 
a})ron,  sits  or  stands  facing  the  patient. 

Method  of  operating :  The  jirst  dcp  in  the  operation  is  to 
confirm  the  diagnosis  of  the  foetal  position  by  a  combined 
internal  and  external  examination.  The  various  steps  of  the 
oj)eration  of  turning  the  f(ctus  are  then  planned,  and  a  deci- 
sion made  as  to  which  hand  shall  be  introduced  into  the  uterus 
and  which  foot  of  the  infant  seized. 

When  the  long  axis  of  the  foetus  is  in  the  long  axis  of  the 
uterus,  the  operator  should  introduce  tlic  lictnd  which  corresjjoiids 
to  the  side  of  the  mother  toicard,  irhich  the  presentinf/  part  is 
directed.  Thus  in  !>.  ().  A.  or  \j.  O.  P.  positions  the  left  hand 
is  introduced  into  the  uterus.  In  such  cases  the  anterior  foot 
should  always  be  seized.  In  ease  of  doubt  both  feet  may  be 
brought  down. 


VERSlOyS.  397 

Wlion  tho  long  axis  of  the  fu'tiis  is  transvorso  to  the  axis 
of  tho  uterus  t/ir  /kiikI  to  be  introdiaud  is  the  one  irliich  rorrr- 
sj)(>tnl.i  to  the  side  of  the  mother  to  irhich  the  hreeeh  is  direeled. 
When  the  breeeh  is  directed  to  the  mother's  right  side  the 
operator  sliould  introduce  his  right  liand. 

In  dorso-anterlor  positions  tiie  near  foot  should  ho  sei/ed 
and  brought  down,  and  in  dorsopoi  terior  positions  tli<'  remote 
foot.  Thus  when  the  child's  hack  Is  directed  to  (he  front, 
seize  the /yon^  (near)  ^'jot ;  when  the  back  is  directed  to  the 
back,  seize  the  back  (remote)  foot. 

Before  introduction  the  hand  and  arm  should  be  dipped  in 
creolin  solution  or  smeared  with  sterilized  oil. 

The  hand,  with  the  tips  of  the  lingers  and  tlnuub  placed 
together  ,s'o  as  to  form  a  cone,  is  then  introduced  through  the 
vagina  and  cervix  with  a  rotary  motion.  The  uterus  shouhl 
always  be  entered  with  the  jialm  of  the  hand  directed  toward 
the  abdomen  of  the  fretus.  The  hand  should  be  ])ushe(l 
steadily  though  gently  n])ward  to  the  fundus,  where  the  feet 
are  usually  to  be  found.  A  conunon  mistake  of  inexperienced 
operators  is  to  feel  about  for  the  feet  before  the  hand  has  been 
introduced  far  enough.  The  foot  can  be  easily  recognized  by 
the  prominence  of  the  heel  and  malleoli. 

The  e.vternal  Itaiid,  j)rotected  with  a  sterilized  towel,  should 
co-operate  by  making  counter-pressure  on  the  fundus,  in  order 
to  steady  the  fetus  as  well  as  to  press  tluj  breech  down,  so  that 
the  feet  may  more  easily  be  reached. 

If  the  membranes  be  found  intact,  they  should  be  rvjdnred 
and  the  hand  pushed  (piickly  uj),  in  order  that  the  forearm 
may  plug  the  vagina  and  so  prevent  escape  of  the  licpior 
amnii.  Should  nterinc  contraction  occur,  tlu^  hand  with  the 
fingers  extended  should  be  held  quiet  until  relaxation  has 
taken  place. 

If  the  shoulder  he  found  impacted  in  the  ])elvis  and  an  arm 
prolapsed,  a  noose  of  gauze  bandage  or  ta])e  shoidd  be  slipj)ed 
over  the  child's  wrist,  and  then  the  impaction  may  be  reduced 
by  gentle  upward  pressure  upon  the  body  of  the  fVetus, 

In  reducing  an  impaction  of  the  fcetus  the  same  rule  ap- 
plies as  in  the  reduction  of  an  impacted  hernia,  "  The  part 
that  has  come  down  last  should  b'^  returned  first."  Thus  the 
upward  pressure  should  first  be  ap})lied  to  that  portion  of  the 


398  OBSTETRIC  OPERATIONS. 

fu'tus  nearest  tlio  pelvic  brim,  and  then  successively  along  the 
body  until  the  apex  of  the  siioulder  is  reached. 

\Vhen  (I  xccarc  (/r(t,sp  of  the  desired  J'oot  has  been  obtaincjd 
it  is  drawn  steadily  down  toward  the  pelvic  outlet,  the  external 
hand  at  the  same  time  bein^^  employed  in  directing  the  head 
toward  the  f'ui;dus.  This  turning  movement  should  only  be 
made  when  the  uteius  is  eh    rely  relaxed. 

The  operation  may  be  con-sidcrrd  <is  vohiphic  when  the  child's 
breech  is  engaged  in  the  pelvic  iidet.  When  possible  the  case 
should  then  be  left  to  nature  to  complete  the  delivery. 

After  the  completion  of  version  tiie  ftetal  heart  should  be 
auscultated  and  the  general  condition  of  the  mother  ascer- 
tained. Should  either  be  at  fault  the  ca^<i  should  be  termi- 
nated by  rapid  extraction  of  the  foetus. 

For  details  as  to  the  various  methods  of  extract ioti  of  the 
breech,  the  reader  is  referred  to  the  section  on  the  Management 
of  Breech  Cases. 

The  dangers  of  internal  version  are  :  laceration  or  rupture 
of  the  uterus  from  the  employment  of  undue  force,  hemor- 
rhage, shock,  and  subsecpient  sepsis  from  uncleanliness  at  the 
time  of  operation.  In  order  to  prevent  the  latter  the  uter- 
ine cavity  should  be  douched  with  a  hot  antiseptic  solution 
(formalin,  1  :  500)  as  soon  as  the  placenta  has  been  delivered. 


SYMPHYSIOTOMY. 

Definition:  Derived  from  a'jtupuair:,  a  joint,  and  ro/iyy,  a 
cutting,  sym|)hysiot6my  is  the  term  applied  to  the  operation 
of  section  of  the  symphysis  pubis  in  a  woman  in  labor.  The 
oh]ect  of  the  operation  is  to  increase  the  diameter  of  a  con- 
tracted pelvis,  and  thus  to  j^ermit  the  delivery  of  a  living 
child  through  the  natural  passages. 

History:  The  operation  was  first  performed  successfully  by 
Sigault,  in  Paris,  in  1777.  It  was  comparatively  popular  dur- 
ing the  early  decades  of  the  present  century,  but  fell  into  dis- 
repute by  1858. 

In  1866  the  operation  was  successfully  revived  by  Morisani, 
of  Naples,  to  whom  is  due  the  chief  credit  of  the  improved 
technique  of  the  modern  operation.     It  was  reintroduced  into 


SYMrnYsjOTOMV.  :v.)\) 

Paris  by  Piiiard  in  1H92,  and  was  first  porforincd  in  America 
by  Jt'\v("tt,  on  St'i  t.  :\i),  l.S|)L>. 

Rationale  of  symphysiotomy:  Tlio  scpiiration  (A'  the  sym- 
physis (uusos  a  k'nii^tiicnin*:;  of  tlic  diamcti'i's  of  t^ic  pelvis,  llie 
conjnii'ate  lu'inj;  the  one  atfeeted  most  in  conseijiicnee  of  tiio 
ends  (»f  the  pnWie  hones  moving  downward  as  well  as  outward 
when  ^e[>ar"iited.  The  (h'seent  of  the  ;5ei);irated  ends  is  (hie  to 
the  fact  that  each  of  th*'  sacro-iliac  joints  roljitcs  upon  an 
oi)li(|ne  line  rnnnint;  from  above  downward  and  tVoni  without 
inward.  A  separation  of  .'jcm.  (li  inches)  (pauses  a  descent  of 
2  cm.  [l  incli)  ;  still  further  descent  being  canse<l  by  tlie  down- 
ward pressure  of  the  f(ctal  head.  The  separation  of  the 
pubi(^  bones  also  peiinits  the  anterior  parietal  eminence  of  the 
fetal  head  to  project  into  the  interpnbic  space. 

Thus  symphysiotomy  results  in  (.'nlargement  of  the  pt'lvic 
canal  by  the  separation  and  descent  of  the  cuds  of  the  j)ui)ic 
bones,  and  by  permitting  a  j)r()minence  of  the  lietal  head  to 
o<;cupy  the  interpubic  space. 

Indications:  Symphysiotomy  hoMs  a  place  between  Ca'sa- 
rean  section  and  the  minor  opei'atious  of  forceps  and  version. 
It  is  an  operation  designed  to  secure  the  birth  of  a  living  and 
viable  child,  and  its  chief  rivals,  in  moderate  degrees  of  pelvic 
narrowing,  are  the  induction  of  j)remature  labor  and  version 
or  force))s  at  term.  TIk?  following  constitute  the  rh'wf  indicd- 
tions  tor  svmphvsiotomv  : 

1.  Simple  flat  pelves  with  a  conjugata  vera  between  7  and 
9  cm.  (2.6  and  o.l  inches). 

2.  Generallv  contracted  ])elves,  with  a  conjugata  vera 
between  8.2  and   10  cm.  (:12  and  .'3.9  iiu'hes). 

8.  Impacted  or  irreducible  mentoposterior  jiositions  of  the 
face. 

4.   Impacted  occi))itoposterior  positions  of  the  vertex. 

Ankylosis  or  any  diseased  condition  of  the  sacro-iliac  joints, 
and  the  presence  of  infection  contraindicate  tiie  operation. 

The  time  for  operation  is  at  the  completion  of  the  first  stage 
of  labor. 

Preparations:  The  i)if<frumenfi<  re(piired  for  the  operation 
are:  a  common  scalpel,  a  slightly  cui-ved,  blunt-pointed  bis- 
toury, a  (xalbiati  or  a  Farabanif  knifi',  a  metal  female  catheter, 
curved  needles,  needle-forceps,  a  few  luumostatic  force])s,  an 


400  OliSTKTRIC  OPERATIONS. 

intra-iitcriiic  (lotu'lic  iio/zlc,  iiiid  n  \)iur  of  axis-tractioi, 
forceps. 

The  following  inatcrUdH  should  also  he  prepared  :  iodofoim 
^aiizc  strips,  pledgets  of  ahsorhont  cotton,  sutures  of  cat^iil, 
silk\voriii-t:;nt,  ;iiid  silk,  i(Klofonn  and  h^iric  powder  (1  :  8),  ;i 
sin-^ical  dressinji;  composed  of  io<loforni  j^an/.e  and  ahsorlieiit 
cotton  pads,  all  of  which  shonld  be  sterilized.  Jinhher  iidiie- 
siv(!  j)lastei'  slionld  be  provitled  to  keej)  the  dressing  in  phice, 
and  also  a  bin.ler  of  strong  cotton,  or,  better  still,  of  can\!is, 
fastening  with  two  or  three  broad  strips  of  tlu;  same  materinl 
provided  with  suitable  buckles. 

The  jMiticut  should  be  prejinred  as  for  an  abdominal  o])era- 
tion,  the  ])ubic  region  shaved,  and  {\\v.  vagina  sterilized.  A 
suitabhi  table  should  be  ready  on  which  to  place  the  ])atient 
during  the  operation.  Tlu'ce  assistants  are  recjuired,  one  to 
give  the  ana'sthetie,  and  two  to  snjiport  the  ])atient's  thighs 
and  give  what  other  help  the  oj)erator  may   recpiire. 

Sterile  saline  solution  should  be  j)rejiared  in  case  of  severe 
hemorrhage  or  shock,  and  other  suitable  restoratives  should 
be  handv. 

Preparations  shouhl  also  be  made  for  the  establishment  of 
respiration  should  the  child  be  born  asiihyxiated. 

The  operation:  There  are  two  methods  of  performing  sym- 
physiotomy, the  Italian  and  the  French. 

Italian  method:  The  (((lr(()tt<(f/e.s  of  this  method  arc  that 
the  wound  is  more  readily  ke])t  from  infection  after  delivery, 
and  that  the  bladder  and  urethra  are  less  liable  to  injurv 
during  the  o))eration. 

The  patient,  having  been  anaesthetized,  is  placed  in  the 
dorsal  position  uj)on  the  table  with  her  thighs  somewhat 
flexed  and  sup])orted  by  two  assistants.  The  operator  then 
notes  the  depth,  direction,  and  thickness  of  the  pubis,  and 
locates  the  central  depression  on  its  upper  margin  which 
indicates  the  })osition  of  the  symphysis. 

Standing  on  the  right-hand  side  of  the  patient,  the  ojierator 
makes  a  vertical  incision  an  inch  long  in  the  abdominal  wall 
terminating  at  a  j)oint  1  em.  (f  inch)  below  the  npper 
margin  of  the  symphysis.  The  incision  should  extend  down 
to  the  superficial  fascia.  An  assistant  then  inserts  a  metal 
catheter  in  the  woman's  urethra,  holding  it  down  and  to  one 


SY.UI'IIYSIOTUMV.  lOl 

side  so  as  to  he  clear  of  the  sympliysis.  Tlic  attacliiiuMits  of 
tlic  recti  to  the  jmhes  are  then  cut  siillicieiitly  to  permit  tlie 
iMtroduetion  of  the  foreliii<ier.  'I'lie  torefiiiucr  of  the  h-ft 
hand  is  then  insert«.;(l  into  tlie  wound  an<l  passed  down  heliind 
tlie  svnii)hvsis.  Occasionally  tlie  f(etal  head  inav  press  so 
close  to  the  piibes  that  the  operator  may  fiml  dillicnlty  in 
insertinii-  his  fiiiixer  beliin<!  the  svmi)hvsis.  In  such  <'ases  tlu^ 
f(etal  Ilea' I  shoid<l  be  pushed  up  out  of  tlie  way  by  an  assist- 
ant with  his  Hnj^ers  in  tlu   va<;iMa. 

The  retropubic  tissucj  arc  separated  by  the  in(k'X-tinL:;er,  as 
it  is  pushed  down  behind  the  sympliysis  and  hooked  undi'r 
the  subpubic  liirament.  The  curved  blade  of  the  (ialbiati 
knife  is  thei.  uiiided  aloui;  the  inde.\-lin<i-er  of  the  left  hand 
into  a  position  behind  the  joint,  so  that  its  top  passes  under 
the  sul)[)ul)i(!  litrament.  In  place  of  the  (ialbiati  kniie  an 
ordinary  blunt-pointed,  slightly  curved  bistoury  may  be 
used. 

The  Join f-sfriicfitrcs  are  then  divided  with  an  upward,  for- 
ward rocking  movement  of  the  knife.  While;  the  j<)int  is 
being  cut  through,  the  sides  of  the  pelvis  should  be  supported 
by  the  assistants,  in  order  to  prevent  the  ends  of  tlu;  bones 
separating  too  much.  Fre([Ueutly  one  fails  to  cut  the  sub- 
pubic ligament  in  cutting  through  the  joint,  in  which  ease  it 
should  inuiiediatelv  be  severed  bv  means  of  a  bhuit-pointed 
bistoury. 

Usually  pretty  severe  hcinorrhdf/c  follows  t\w-  section  of  the 
joint,  but  firm  packing  of  the  wound  with  iodoform  gauze 
invariably  checks  it.  After  the  joint  has  been  divided  the 
catheter  may  be  removed  from  the  urethra. 

Wiiile  o(;casionally  a  woman  may  be  allowed  to  (U'liver 
lierself  after  the  symphysis  has  been  divided,  as  a  general 
nde  it  is  better  to  terminate  the  labor  at  once  hy  forcep.s  or 
vcffiion. 

During  tlie  delivery  the  assistants  should  exert  firm  lateral 
pressure  upon  the  pelvis,  to  prevent  too  wide  sc))aration  of 
the  pubic  bones;  the  bones  should  not  be  allowed  to  separate 
more  than  <>.5  to  7  cm.  (2.5  to  2.7  inches). 

After  delivery  has  been  completed  the  patient's  thighs  should 
be  extended  and  her  knees  brought  together.  The  oj)eratoi', 
after  having  washed  his  hands,  removes  the  gau/e  packing 

26— Obst. 


402  omTKTRK'  OPKRATloyS. 

from  tlie  woiiiid  iind  ]>ass('s  liis  left  indcx-fin^or  hcliiiid  the 
joint  to  make  sure  tliat  the  Idaddcr  has  not  hccii  cautilii 
Ix'twceii  tlic  boiu's  ;  tlu'ii  liavin*;  clMcUcd  all  liciiiorrliajxi',  lu' 
siitiiros  iIr'  wound  with  three  or  t'oiir  deep  sllUworin-mnt 
sutures.  Most  operators  consider  it  unneeessary  to  attempt 
to  suture  the  hones  to<:;etlier  ;  on(!  or  two  sutures,  however, 
may  be  placed  so  as  to  include  the  Hlwous  tissue  on  the  ante- 
rior surface!  of  the  joint. 

Vaginal  and  vulvar  lacerations,  if  present,  are  then  re- 
|)aired,  and  the  bladder  and  urethra  examined  for  ])ossible 
injuries.  The  abdominal  wall  is  then  drc^ssed  with  a  sti'ij)  of 
iodofoiMu  ti:auze  and  covered  with  lavers  of  absorbent  cotton. 
'J'his  dressing  is  iield  in  phuic  by  means  of  one  or  two  bi-oad 
strips  of  rubber  adhesive  plaster  which  pass  well  behind  the 
wings  of  the  pelvis  on  either  side. 

A  firm  cotton  binder  is  then  aj)plied,  or  a  broad  canvas 
belt  whi(;h  can  be  fastened  by  means  of  straps  and  buckles. 
The  patient  is  then  removed  to  a  bed  witli  a  firm  level  mat- 
tress, sucii  as  would  be  used  for  a  fracture  case.  It  is  ad- 
vantageous to  su]>port  the  sides  of  tlie  ])elvis  with  sand  bags 
reaching  from  the  knees  to  above  tlie  waist.  Tlie  patient's 
knees  should  be  tied  togetiier. 

French  method :  The  chief  advantage  of  this  method  is  that 
on  account  of  the  long  incision  the  operator  can  see  what  he 
is  doing  at  each  step. 

The  operation  ;  An  incision  three  inches  long  is  made  begin- 
mintr  on  the  abdominal  wall  one  and  one-half  inches  above 

- 

the  symphysis  and  extending  downward  to  the  clitoris.  The 
edges  of  the  wound  are  separated  by  retractors  and  the  exact 
location  of  the  symphysis  d(4ermined. 

By  careful  dissection  first  th(>  lower  and  then  the  upper 
margins  of  the  symphysis  are  exposed.  An  index-finger  is 
then  inserted  behind  the  joint  so  as  to  detach  the  retropubic 
tissues.  A  broad,  flat,  grooved  director  is  then  guided  along 
the  index-finger  behind  tlu;  joint,  either  from  above  down- 
ward or  from  below  upward.  The  joint  is  then  cut  fr(»ni 
without  inward  by  means  of  a  Farabceuf  knife.  During  de- 
livery the  wound  is  })acked  with  iodoform  gauze  to  prevent 
possible  infection. 

After  delivery  the  wound  is  sutured  with  strong  silkworm- 


.S'  YMPIl  YSrn  TOM  Y.  4  Oli 

^iit,  tho  sutures  hciuii^  ^'»  pnsscd  as  to  include  tlie  Wvux  tihrous 
outer  (!()veriu^-  of  the  ends  of  the  hones. 

After-treatment :  'I'lir  atter-enre  of  a  svtni)h\>iotoinv  ease 
is  usually  very  trouhlesoiue,  the  dillicidlits  hciu^  to  keej)  the 
wound  from  infection  and  to  prevent  separation  of  the  ends  of 
the  pubic  hones.  'I'here  is  usually  very  considerahle  u'di'Uia 
of  the  vidva  j)r('seut  for  several  days  after  the  ojx'ratiou. 

Special  attention  should  he  i)aid  to  the  f(>i/<f  o/  f/if  ni/ra. 
(ieiierallv  the  catheter  must  he  used  for  several  davs  each 
time  it  is  desired  to  emj)ty  the  bladder,  A  strong  assistant 
should  beat  hand  tosuppoi't  and  lift  the  pelvis,  while  a  nurse 
slips  the  bed-pan  under  the  buttocks.  The  knees  shoidd  be 
ke})t  tied  toj;ether  for  two  weeks  and  the  patient  kept  flat  on 
her  back  for  three  or  four  weeks.  The  sutures  mav  be  re- 
moved  on  the  sixth  to   the  tenth  day. 

Should  it  be  ne(;essary  to  disinjccf  the  parturient  cdiitil 
durinjr  the  jMierperium,  the  patient's  lei;s  should  be  raised 
straight  in  the  air  without  ben<lin^  the  knees  and  supported 
by  an  assistant.  Jn  this  way  whatever  treatment  may  be 
re<iuircd  can  be  carried  out  without  causing  the  patient 
much  inconvenience. 

The  patient  may  be  allowed  to  sit  up  in  from  three  to  four 
weeks  after  the  operation,  but  should  not  be  allowcid  to  walk 
about  mu(;h  before  the  sixth  week. 

Dangers  of  symphysiotomy:  In  Italy  54  symiiliysiotomies 
have  been  performed,  with  but  2  maternal  deaths.  Jn 
America  the  mortality  is  12  })er  cent.  Under  favorable  con- 
ditions and  at  the  hands  of  skilled  operators  the  maternal 
death-rate  should  be  almost  )iil. 

Failure  of  the  separated  pubic  bones  to  unite  may  leave  the 
woman  with  some  looseness  in  the  joint,  and  cripple  her  ])ow- 
ers  of  locomotion.  The  sacro-iliac  joints  may  be  damaged  by 
too  wide  a  separation  of  the  pubic  bones.  Troublesome 
hemorrhage  frequently  takes  ])lace,  but  can  usually  be  con- 
trolled by  ])ressure  and  luemostatie  suture.  Vesical  and 
urethral  injuries  have  been  re])orted,  flic  anterior  vauinal 
wall  is  liable  to  laceration  during  extraction  of  the  child. 

■  III     i^WT  1^ 

In  the  o])inion  of  the  writer,  the  chief  di'dirheicl:  of  sym- 
physiotomy is  the  great  dislocation  of  the  internal  organs 
which   accompanies   icTrcible   extraction.      Not    infrequently 


404  OliSTF/nUC  (H'ERATIOSS. 

tlicso  cnscs  siilVcr  later  fVoin  |)r()lii|)siis  nicri,  on  Mcconiit  of  tlic 
lax  condition  of  tlir  stnictiircs  of  tlu'  pclxic  outlet  wliieli 
remains  after  the  operation  on  acronnt  of  the  pnhie  hono 
Weinj^  separated  ;  the  wliolc  ineehanisin  of  lahor  is  interfered 
svitli,  so  that  the  head  (.oseends  thi'oiifrh  the  pelvis  in  a  trans- 
verse |)osition,  the  occiput  failiuj:;  to  rotate  to  the  front.  More 
or  less  daniaiic  to  the  j)elvi('  fascia  results  and  fails  to  underiro 
pi'oper  I'epair,  so  that  the  woman  latei  develops  cystocele, 
reetocele,  or  even  a  prolapsus  uteri. 

Failure  to  carry  out  rijrid  aseptic  pre(rantions  after  opera- 
tion inay  lead  to  infection  of  the  N\()nnd  with  serious  con- 
sec  piencos. 

CiESAREAN  SECTION. 

Definition :  Cjesarcan  section  may  be  defined  as  an  obstetric 
operation  for  the  delivery  of  a  mature  fetus  by  means  of  an 
incision  throu<!;h  the  abdominal  and  uterine  walls. 

History:  The  operation  dates  from  i»rehistoric  times.  The 
Krst  recorded  operation  was  performed  by  a  butclier  in  Swit- 
zerland, in  1500.  Until  the  develoj)ment  of  antiseptic  surgery 
th(^  operation  was  attended  by  enormous  fatality,  and  was 
only  j)erformed  as  a  last  resort.  The  uterine  incision  was 
forn\erly  left  nnsutured,as  it  was  snj)posed  that  sutures  would 
not  hold  on  account  of  uterine  contractions. 

Sanger,  of  Leipsic,  has  done  probably  more  than  anyone 
else  to  [)erfect  the  modern  operation.  In  1882  he  showed 
that  the  uterine  incision  could  be  sutured  with  safety  j)rovided 
the  suture-material  employed  was  sterile.  Since  that  time  the 
mortality  attiMiding  the  operation  has  been  steadily  reduced. 
Under  favorable  circimistanees  and  at  the  hands  of  skilful 
operators  the  maternal  mortality  is  about  5  per  cent. ;  but 
in  general  practice  the  mortality,  according  to  Harris,  ranges 
from  150  to  40  per  cent. 

The  indications  for  this  operation  may  be  abt<(>lu(e  or  rclntiir  : 

An  absolute  indication  is  the  presence  of  some  condition 
which  renders  im])ossil)le  any  other  method  of  delivery — e.  //. 
— extreme  degrees  of  pelvic  contraction  (conjugate  under  6.5 
cm.) ;  marked  ])elvic  deformity  resulting  from  osteomalacia, 
kyphosis,  and  spondylolisthesis  ;  foreign  grow'ths  obstructing 


<  '.fASVl RIJA iV  .SAY  "11  ON.  405 

tlio  |)olvI('  canal  ;  cicatricial  <'(mh'a»'ti<»ii  of  llic  vaiilna  ;  and 
carcinoma  of  tiic  cervix  or  ol'  llic  rectum. 

A  relative  indication  is  tlic  jn'cscncc  of  some  condition 
wlii<'h  makes  <loul)tt'ul  tlic  delivery  of  a  living  child  l>y  tlic 
natural  |)assa^es.  In  some  cases  tlie  <jMestion  to  ho  decided 
is  whether  ( 'jesarean  section  or  one  of  the  alternative  opera- 
tions (symphysiotomy,  force|)s,  version,  craniotoniy)  will 
secure  the  Ix'st  residts.  The  inclividnal  |)ecnliarities  of  each 
case  as  it  arises  must  he  studied  hefore  a  decision  can  he  made. 
In  general,  after  consultation  with  a  confrf^ir,  the  j)hysiciau 
should  leave  the  decision  to  the  woman  or  her  hushainl, 
having  explaiiUMl  to  them   the  nature  of  the  case. 

The  commonest  relative  indications  are  :  a  conjuj^ate  of 
6  to  8  cm.  (2.\  to  f'Ji,  inches)  ;  and  tumors  which  cause  hut  a 
moderate  degree  of  pelvic  (►hstruction  (  V\^.  1  17). 

The  hest  time  for  oju-ration,  when  this  is  elective,  is  witiiin 
a  week  of  the  expected  date  of  labor. 

Preparations  for  Csesarean  Section. 

The  patient,  if  ])ossihle,  should  be  under  observation  for 
some  days  before  tlie  o|)eration  is  undertaken.  During  this 
period  the  urine  should  be  examined,  the  diet  restricted,  and 
the  bowels  carefully  regulated.  (iMieral  tonics,  especially 
strychnine,  should  be  given  daily,  if  there  be  any  indication. 

The  evcninq  hcfntr  the  operation  the  patient  should  be 
given  a  full  dose  of  castor  oil,  or  half  an  ounce  of  Ej)som 
salt  in  a  tumblerful  of  water.  Tlie  abdomen  and  piibes 
should  be  shaved  and  scrubbed  with  a  soft  brush,  tincture  of 
green  soap,  and  hot  water.  After  being  thoroughly  rubbed 
with  alcohol  the  abdomen  is  to  be  covered  with  sterile  gauze 
and  a  binder  applied. 

If  the  patient  is  nervous  and  unable  to  sleep,  sul phonal 
(gr.  x-xv)  may  be  given  in  warm  broth  or  milk.  The  fol- 
lowing morning  the  patient  may  be  given  a  cu])ful  of  broth 
two  hours  before  the  operation.  If  the  bowels  hdA'o  not  been 
freely  moved,  an  enema  of  turpentine  ant'  >v'apsuds  (.^j  to  ()j) 
may  be  given. 

Before  the  })atient  is  ])laced  on  the  operating-table  siie 
should  be  catheterized  and  the  abdomen,  vulva,  and  vagina 


400  OBSTETRIC  OVERATIONS. 

fiipilly  .sterilized.  Tlio  vagina  is  tlien  liglitly  packed  with 
iodoform  gauze. 

After  tlie  patient  is  placed  on  the  operating- table  the  chest 
and  thighs  are  covered  with  blankets  j)rotected  by  sterilized 
towels,  and  a  large  piece  of  sterilized  gauze  coni])osed  of  four 
thicknesses  is  arranged  so  as  to  cover  the  whole  body  from 
chest  to  knees. 

The  usual  dresshigH  and  acce.sHorics  for  an  abdominal  opera- 
tion should  be  provided  in  addition  to  the  following  instru- 
ments : 

2  scalpels, 

1  pair  of  ordinary  scissors. 

1  dozen  artery-forceps, 

1  pair  of  retractors. 

Curved  and  straight  needles, 

1  needle-holder. 

A  large  thin-walled  rubber  tube  as  a  uterine  ligature, 

Silk,  silkworm-gut,  and  catgut  for  sutures  and  ligat.ires. 

Four  assistants  are  required — one  to  give  the  ansesihetic, 
one  to  compress  the  cervix  and  control  hemorrhage,  one  to 
receive  and  attend  to  the  child,  and  one  to  assist  the  operator 
throughout  the  operation. 

The  Csesarean  Operation. 

The  operator  first  cuts  a  slit  in  the  gauze  extending  from 
the  pubes  to  a  short  distance  above  the  umbilicus. 

An  incision  is  then  made  in  the  linea  alba  extending  from 
a  ])oint  4  cm.  (1|  inches)  above  the  pubes  to  a  point  the  same 
dista»  ce  below  the  umbilicus.  The  peritoneal  cavity  is  then 
opened  with  the  usual  precautions.  Such  an  incision  is 
sufficient  for  the  introduction  of  the  hand  and  the  withdrawal 
of  the  child.  Many  operators  prefer,  however,  to  extend  the 
abdominal  incision  to  a  point  above  the  umbilicus,  and  to 
turn  the  uterus  out  of  the  cavity  before  incising  it. 

The  advantages  claimed  for  this  laffer  method  are  :  a  saving 
of  time,  better  control  kS  the  uterus,  and  that  it  is  easier  to 
])revent  the  entrance  of  fluids  into  thc^  general  peritoneal 
cavity.  Its  disadvantages  are  :  the  great  length  of  the  ab- 
dominal  incision,  which   predisposes  to  hernia  later;  and  the 


CMS  A  RE  AN  SECTION.  407 

greater  extent  of  adliesions  oecurriiig  later  between  the  ab- 
dominal wall  and  the  nterns.  For  these  reasons  the  shorter 
ineision  is  generally  to  he  preferred. 

Having  exposed  the  uterus  to  view,  the  operator  then  passes 
a  piece  of  rnhber  tubing  over  the  fundus  and  down  to  the 
lower  segment,  so  that  it  will  encircle  the  uterus  below  the 
presenting  })art  of  the  child  ;  the  ends  are  given  to  an  assist- 
ant, who,  l)y  exercising  traction,  compresses  the  uterus  and 
steadies  it  against  the  symphysis,  thus  eontrolling  hemorrhage. 

An  incision  is  then  made  into  the  uterus  extending  from  tlie 
fundus  to  just  above  the  retraction-ring.  This  incision  must 
be  made  quickly  and  boldly  in  spite  of  the  severe  hemorrhage 
whicii  occurs. 

Extraction  of  child:  The  operator  then  plunges  his  hand 
into  the  cavity  of  the  uterus,  pushing  to  one  side  the  placenta 
if  it  be  encountered,  seizes  the  chi'd  by  a  foot,  and  extracts  it 
as  raj)idly  as  possible.  While  the  uteri  le  incision  is  being 
made  the  assistant  should  press  the  abdominal  wall  to  the 
sides  of  the  uterus,  to  prevent  the  entrance  of  fluids  into  the 
peritoneal  cavity.  As  soon  as  the  child  is  extracted  the 
utarus  usiially  contracts.  When  the  child  is  withdrawn  from 
the  uterus  it  is  given  to  an  assistant  to  hold,  while  the  o])era- 
tor  clamp-i  the  cord  in  two  places  with  artery-forceps  and  cuts 
between  them. 

The  placenta  is  then  grasped  on  its  foetal  surface;  and 
loosened  from  its  attachment  by  simply  squeezing  it.  The 
membranes  peel  off  from  the  uterine  wall  as  the  placenta  is 
withdrawn  through  the   incision. 

Should  the  uterus  fail  to  contract  properly,  it  may  be 
stimulated  by  the  applicaticm  of  hot  cloths  and  friction. 

It  is  then  lifted  out  of  the  abdominal  cavity  and  a  large 
piece  of  gauze  slipped  under  it,  to  hold  it  and  also  to  prevent 
the  intestines  protruding. 

After  some  iodoform  powder  has  been  dusted  into  the 
cavity  the  uterine  wound  is  closed  bv  means  of  silk  sutures. 
These  si  *^ures  are  placed  at  intervals  of  about  1.5  cm.,  or 
about  half  an  inch,  and  should  include  only  the  muscular  coat. 
The  peritoneal  edges  are  then  approxi'.nated  by  a  second 
layer  of  interrupted  silk  sutures,  placed  at  shorter  in.tervals 
than  the  first  layer.     After  the  sutures  have  been  tied  there 


408  OBSTETRIC  OPKIiATtONS. 

shoukl  l)e  no  lionK)i'rlmf2;(>  oitlior  from  tlio  wound  or  from  tlio 
utHMlle-pimctiirt's.  When  tlic  utorine  wound  has  been  sutured 
the  clastic  ligature  around  the  cervix  may  he  withdrawn. 

Closure  of  abdominal  wound:  The  abdominal  cavity  should 
then  be  sponged  dry  with  cheesecloth  sponges,  particular 
attention  being  paid  to  the  renal  fossjc. 

Having  returned  the  uterus  to  the  abdominal  cavity  and 
placed  \^  in  proper  position,  the  omentum  is  then  to  be  brought 
down  and  carried  behind  instead  of  in  front  of  it,  in  order  to 
avoid  omental  adhesions. 

The  abdominal  incision  is  then  closed  in  the  usual  manner 
and  a  surgical  dressing  applied.  The  vaginal  gauze  is  then 
removed  and  a  vulvar  pad  applied. 

After-treatment:  The  after-treatment  should  be  much  the 
same  as  after  any  abdominal  operation.  During  the  first 
twenty-four  hours  it  may  be  necessary  to  give  a  hypodermic 
injection  of  morj)hine  for  the  relief  of  ])ain.  The  child  r-^'^w 
be  put    to  the  breast  after  twenty-four  hours  have  ela        .. 

Special  attention  should  be  given  to  the  care  of  the  vui.a, 
in  order  to  prevent  infection  of  the  vagina. 

The  abdominal  sutures  may  be  removed  from  the  tenth  to 
the  fourteenth  day,  and  the  patient  may  be  allowed  out  of  bed 
at  the  end  of  three  weeks.  An  abdominal  support  should  be 
worn  for  six  months  after  the  opeiation. 

Porro  Operation. 

In  1876  Porro  suggested  that  the  ordinary  Ciesarean  opera- 
tion should  be  supplemented  by  the  amputation  of  the  uterus 
along  with  the  tulies  and  ovaries. 

After  amputation  of  the  uterus,  two  methods  of  treating  the 
stump,  are  available. 

Ry  the  extraperitoneal  method  the  stump  is  transfixed  by 
long  needles  and  retained  in  the  lower  angle  of  the  wound. 

By  the  intraperitoneal  method  the  stump  is  sewed  over  in 
such  a  manner  as  to  cover  it  completely  with  ])eritoneum, 
after  which  it  is  drop])ed  into  the  abdominal  cavity. 

The  advantages  of  the  Porro  operation  ar(>  that  it  rend(>rs 
subsequent  uterine  hemorrhage  or  conception  impossible,  and 
decreases  the  risk  of  puerperal  infection,  while  it  adds  nothing 
to  the  danger  of  the  operation. 


SELECTION  OF  OBSTETRIC  OPERATIONS.  409 

Indications  :  Orlioliystcn'ctoniy,  or  Porro-Ciosjiroan  soction, 
is  indicated  when  labor  lias  hoeii  |)rolon<::('«l  and  nianipidations 
have  been  attempted  to  .secure  delivery,  hut  have  tailed  and 
sepsis  is  j)rol)ahle  ;  when  the  uterus  or  its  apj)enda^es  are  so 
diseased  as  to  require  a  subsequent  operation  for  their  •enioval ; 
and  when  any  condition  is  present  which  will  make  it  impos- 
sible for  a  child  to  be  delivered  subsequently  by  the  natural 
passages. 

The  preparations  are  the  same  as  for  Cttsarean  section, 
except  that  the  following  indrurnenfx  should  be  added  to  the 
list  given  previously  :  1  large  pedicle-scissors ;  4  curved 
large  pedicle-clamps  ;  2  large  volsellum  forceps;  2  right  and  2 
left  aneurisrr>-needles  ;  and  1  right  and  1  left  sharp-])ointed 
pedicle-needles. 

Operation :  The  abdominal  incision  should  extend  from  two 
inches  above  the  umbilicus  to  just  above  the  symphysis.  The 
uterus  is  drawn  up  out  of  the  abdomen,  and  a  sterile  towel  is 
packed  into  the  peritoneal  cavity  to  jirevent  the  escape  of  the 
intestines.  The  assistant  then  draws  the  edges  of  the  alxlomi- 
nal  incision  close  about  the  cervix,  whi(!h  he  grasps  tirndy 
with  both  hands  so  as  to  control  hemorrhiige  when  the  uterine 
incision  is  made. 

The  uterus  is  then  incised  an  1  the  child  and  placenta 
removed  as  quickly  as  possible.  The  ovarian  arteries  are 
then  sought  and  tied,  as  also  the  arteries  of  the  round  liga- 
ments. The  broad  ligaments  are  then  clamped  and  cut ; 
peritoneal  flaps  for  covering  over  the  stump  are  tin  n  pre- 
pared, the   uterus  amputated,  and  the  uterine  arteries   tied. 

The  stump  is  then  oversewn  and  dropped,  the  peritoneal 
cavity  is  washed  out,  and  the  abdominal  wall  closed. 

GENiSRAL  RULES   GOVERNING   THE    SELECTION  OF  OB 
STETRIC    OPERATIONS    IN   CASES   OF    OBSTRUCTED 
LABOR. 

Conjugate  of  9.5  cm.  or  less:  The  best  method  is  to  induce 
labor  at  or  about  four  weeks  before  the  ex])ected  termination 
of  pregnancy.  Tf  the  condition  of  the  pelvis  is  only  discov- 
ered after  labor  has  begun,  the  labor  may  be  allowed  to  go  on 
for   twenty-four   hours.      Atter^ion    should  be   paid    to    the 


410  OnSTETRW  OPERATIONS. 

woman's  general  condition  and  tlie  distention  of  the  lower 
uterine  segment,  'llie  (choice  of  operation  then  lies  between 
for(!ej)S,  version,  symphysiotomy,  and  Cjesarean  section. 

Forcepti  may  1)6  applie<l  and  the  patient  j)lii('ed  in  tiie 
Waleher  position  ;  if  after  twenty  mimites  tiie  liead  does  not 
become  engaged,  tiiey  should  be  discarded.  \^crsioii  may  suc- 
ceed wiiere  tiie  forceps  liave  failed,  but  the  risk  for  the  child 
is  considerable.  If  the  danger  of  version  is  considered  too 
great  to  risk,  then  s i/mph i/'sioto  ni/ ahouUl  be  done.  If  after 
the  pubis  has  been  divided  the  head  descends  to  the  brim,  the 
delivery  may  be  completed  by  forceps.  Should  the  head 
remain  high  after  separation  of  the  pubes,  then  version  offers 
a  more  favorable  result  to  the  child. 

The  most  important  comUiioiDi  ofectbu/  the  choice  of  opera- 
tion are  the  size  and  compressibility  of  the  feetal  head.  A 
compressible  head  may  pass  through  a  pelvis  that  would  ju'ove 
an  insuperable  obstacle  to  an  incompressible  head  of  the  same 
size. 

The  relative  size  of  the  head  and  pelvis  may  be  (ipproxi- 
mately  detennined,  by  grasping  the  head  firmly  with  the  ex- 
tended fingers  placed  on  the  abdominal  wall,  and  pressing  it 
down  upon  the  pelvic  brim  for  some  time.  The  pressure 
thus  exerted  should  be  in  the  axis  of  the  pelvic  inlet.  If  the 
head  can  thus  be  forced  within  the  brim,  the  natural  forces 
will  certainly  secure  the  engagement. 

Conjugate  of  7  cm.  or  less :  If  at  the  thirty-sixth  week  the 
head  can  be  forced  into  the  brim  by  steady  pressure  from 
above,  labor  should  be  induced.  The  risk  to  the  child  of  in- 
ducing labor  before  the  thirty-sixth  week  is  too  great  to  afford 
much  chance  of  its  surviving  its  birth.  If  at  this  time  the 
head  is  too  large  to  engage,  the  case  should  be  left  till  about 
term  and  Qesarean  section  j)erformed.  Embryotomy  should 
never  be  performed  upon  a  li\  ing  child  if  it  |>ossibly  can  be 
avoided.  On  the  other  hand,  Ctesarean  section  should  not 
be  rashly  undertaken  by  an  oj)erator  unskilled  and  iuex- 
])erienced  in  abdominal  surgery.  As  before;  said,  the  final 
decision  should  be  left  to  the  ])atient  or  her  nearest  dila- 
tions. 

When  the  pelvic  canal  is  obstructed  by  a  tumor  which  can- 
not be  dislodged  or  which  would  be  subjected  to  dangerous 


kMBUYOTOMY.  \\\ 

|)i'essiire  during  tlic   passa'i;^  of  llio  child,  tlio   safest  inctlio! 
of  delivery  would  be  Ctesarean  seeti(»n  or  the  Porro  operation. 

EMBRYOTOMY. 

Definition:  Etnhri/ototni/  is  a  generic,  term  which  includes 
all  the  destructive  operations  by  which  the  volume  of  the 
fo'tus  is  reduced  to  permit  of  its  extraction  throuj^h  the  natu- 
ral })assages.  The  term  thus  includes  crdiildtoini/,  dccdpita- 
tioUy  evuHceratlon,  and  wnputation  of  the  extmnit'u'x. 

Indications :  Emhrvotomv  should  never  be  i)erformed  on  a 
liv'uKj  child  when  any  other  obstetric  operation  otfers  a  reason- 
able chance  of  savinu;  its  life. 

The  patient  and  her  friends  may  decline  any  conservative 
operation  and  insist  on  embryotomy.  In  such  <!ase,  if  the 
physician  is  of  opinion  that  a  conservative  operation  would 
offer  a  reasonable  chance  of  saving  the  child,  he  is  at  liberty 
to  transfer  the  case  to  some  one  else  should  he  so  desire. 
When  such  a  course  is  not  open  to  him,  the  physician  must 
und -r  protest  yield  to  the  desire  of  the  patient  and  her  friends, 
as  he  has  no  legal  right  to  compel  them  to  follow  his  judg- 
ment. 

Provided  the  foetus  is  dead,  the  following  conditions  may 
be  mentioned  as  constituting  the  ordinary  indications  for 
embryotomy  : 

1.  Deformity  of  the  jielvis  where  forceps  or  version  is 
impossible,  or  would  ex])ose  the  mother  to  unnecessary  risk. 

2.  Obstruction  of  the  parturient  canal  by  tumors — uterine, 
ovarian,  malignant,  or  osseous. 

3.  Impaction  of  the  presenting  part :  face  presentations, 
occipitoposterior  positions,  locked  twins. 

4.  Eclampsia,  or  other  causes  demanding  raj)id  delivery 
where  forceps  or  version  would  be  ditHcult  or  ])rolonged. 

5.  jSIonstrosities  ;  hydrocephalus ;  the  latter  constitutes  an 
indication  for  embryotomy  on  the  living  child,  for  if  the 
condition  is  so  marked  as  to  prevent  delivery  there  is  !io 
probability  of  the  child  surviving  should  conservative  opera- 
tion be  performed. 

Embryotomy-instruments  :  The  object  of  embryotomy  being 
to  reduce  the  bulk  of  the  f<etus,  the  presenting  part  has  first 


412 


Oli^TKTRlC  OPERA  TIONS. 


to  he  perforated  and  its  contents  evaeuated.     If  this  proced- 
ure  fails  to  r('(hi(!e   tiic  bulk  of  the  fcetus  sutliciently,   it   is 


Fig.  143. 


Suit    'e  8  scissors 


necessary  then  to  crush   the   presenting  part  by  means  of  a 
powerful  instrument,  so  that  delivery  may  be  accomplished. 
Perforators :  The  best  instruments  for  perforating  the  head 


Fkj.  144. 


Blot's  perforator. 


are  Smellie's  scissors  and  Blot's  perforator  (Figs.  143  and  1  14), 
though  a  pair  of  scissors  with  a  long  handle  answers  the  ])ur- 


FiG.  145. 


Braiin's  cranioclast. 


pose  admirably.     The  Germans  prefer  to  perforate  the  skull 
by  means  of  a  trej)hine  with  a  long  handle. 

Cranioclast:  This  is  a  powerful  instrument  for  seizing  the 


EMBRYOTOMY. 


413 


Fio.  14(;. 


head  {iftor  it  lias  been  perpDrated  (Fi^.  14.")).  It  consists  of 
two  blades,  one  for  insertion  inside  and  the  other  outside  the 
siciill.  At  tiu!  ends  of  tiie  iiandies  tiiere  is  a  powi-rfni  com- 
pression screw  wiiich  enables  tiie  operator  to  obtain  a  iirin 
grip  of  tiie  I  lead. 

Cephalotribe :  Tiiis  instrument  is  sim|)ly  a  heavy  forceps 
speciiaily  modified  for  compressing  tiie  iiead  after  it  has  been 
jierforated  (h^i^.  14()).  Tiie  blad(;s  are  applied  on  either  side 
of  tiie  liead,  wiiicli  is  tlien  crnslied  l)V 
tijjjhtening  a  screw  attaclied  to  the  ends 
of  tiie  liandles. 

Tile  most  [)erfe(!t  instrument  for  reduc- 
ing the  l)uliv  of  tiie  fetal  head  is  Tar- 
nio-'fi  h(()ii()fri()c,  wiiicii  is  at  once  a  |>er- 
forator,  a  cranioclast,  and  a  ceplia]otril)e 
(Fig.  147).  Tliis  instrument  is  composed 
of  a  perforator,  two  heavy  fenestrated 
i)lades  of  uneijual  lengtli,  and  is  provided 
witli  a  })owerful  compression  screw. 

Method  of  use:  After  disarticulating 
tlie  instrument  tlie  pei'forator  is  pushed 
tlirougli  a  suture  or  fontanelle,  the  short 
bla<le  is  then  apj)lied  on  tlie  outside  of 
tlie  liead  like  an  ordinary  forceps  blade, 
and  is  tlien  articulated  with  the  perfora- 
tor, when  the  Cv)mpression  s(;rew  is  tight- 
ened until  the  blade  is  forced  close  to  the 
perforator,  thus  crushing  one  side  of  the 
head. 

After  loosening  the  compression  screw 
the  long  blade  is  ap|)lied  to  the  opj)osite 
siile  of  the  head  and  its  handle  articu- 
lated to  the  handle  of  the  short  blade, 
when  the  screw  is  again  tightened,  thus 
completely  (irushing  the  head.  Thus  the 
base  as  well  as  the  vault  of  the  skull  can 
be  crushed  and  flattened  to  a  little  less 
than  two  inches  (Fig.  148). 

Hook  and  crotchet:  This  instrument  consists  of  a  curved 
metal  bar  terminating  at  one  end  in  a  blunt  hook,  at  the  other 


Lusk's  ccphaliitiihe. 


414 


onsTETRW  orERATwys. 


in  a  crotchet  tip  (Fi^.  141)).  The  crotchet-tij)  end  may  he  in- 
sci'ted  into  the  skull  after  j)erioration  and  hooked  into  the 
foramen  ma<!:ninn,  thus  permitting  tiie  instrument  to  be  used 


Fi(i.  147. 


Fig.  148. 


Tarnier's  basiotrilio. 


Basiotripsy  accomplished. 


as  an  extractor.     The  iiook  may  he  used  to  pull  down  the 
neck. 

Brarut^s  hook,  whicli  consists  of  a  steel  rod  with  a  strong 
transverse  handle  at  one  end  and  a  sharply  bent  hook,  tipped 


EMIUtYOTOMY. 


415 


witii  a  romulc'd  l)Utt()n,  at  tlu;  other,  is  cniployctl  as  a  dcrapi- 
tatur. 

Zwoif'c'l  lias  devised  a  (Iccdjiifafor  wliicli  consists  prat'tically 
of  two  Jirauii's  liooivs  so  arranged  that  by  sepaiatiii^  tlio 
iiandlus  tlu3  tips  can   be  moved  in   opposite  directions. 

In  America,  where  exticnie  decrees  of  pelvic  contraction 
are  rarely  to  he  met  with,  embryotomy  can  nsnally  be  carried 
ont  with  comparatively  little  risk  to  the  mother,  j)rovide(l  the 
operator  is  earefnl  and  moderately  skilful,  by  means  ol"  a  jiair 
of  blunt-pointed  scissors  with  short  blades  and  a  lonp;  handle  ; 
and  an  old-fashioned  hook  and  crotchet.  The  writer  has  per- 
formed seven  embrvotomies  with  these  two  instruments,  and 

Fig.  149. 


Crotchet. 


in  no  case  was  there  laceration  or  ininrv  of  the  maternal  st)ft 
parts,  and  the  mothers  all  made  uneventftd  recoveries. 

The  time  for  operation  is  at  the  conclnsion  of  the  first  stage 
of  labor. 

Preparations  :  The  patient  after  being  anaesthetized  is  placed 
in  the  lithotomy  j)osition  with  her  liij)s  at  the  edge  of  the  bed 
or  table  on  which  she  lies.  The  vulva,  vagina,  and  inner 
surfaces  of  her  thighs  are  then  scrubbed  with  sj)irits  of  green 
soap  and  hot  water,  to  be  followed  w'th  a  douche  of  formalin 
or  bichloride  solution.  I'he  bladder  is  then  catheterized.  The 
douche-bag  should  be  filled  with  sterile  Mater  and  hung  in  a 
position  to  secure  a  good,  forceful  stream. 

The  instruments  to  be  used  in  the  operation  are  then  placed 
in  a  convenient  position  after  being  sterilized. 

Operation. 

The  o])erator,  suitably  pre})ared,  first  makes  a  careful  inter- 
nal examination,  to  ascertain  the  exact  conditi(ms  ])resent.  If 
possible,  the  hand  should  be  passed  into  the  uterus  till  the 
cord  can  be  reached,  to  make  certain  the  fnntus  has  perished. 
When  the  head  is  found  presenting  at  the  brim  it  should  be 
steadied  from  above  by  an  assistant  when  possible. 


416  (HiSTETllIC  OPERATIONS. 

TIk'  perforator:  'V\\i\  operator  tlicn  locates  (lie  suture  or 
foiitaiK'llo  witli  tlie  ti|)sof'tlie  index  and  nii<ldle  tinkers  of  his 
left  hand  j)hiced  in  the  vaj^ina.  Tlie  perforator  hehl  in  his 
ri^ht  liand  is  then  j^nided  into  position  between  the  Hngers  of 
ilie  left  hand  placed  on  the  head.  The  head  is  perforated 
l)v  stea<ly  iij)\vard  j)ressnre  of  the  instrument  hehl  in  the  right 
hand,  ilaving  penetrated  the  skull,  the  perforator  is  swept  in 
every  direction  to  hreak  up  the  bi'ain,  and  the  opening  is 
(Milarged  in  every  direction.  The  dou(^he  no/zle  is  in- 
s(!rted  into  the  oj)ening  in  the  skull,  and,  a  return  How 
having  been  provided  for,  a  stream  of  water  is  let  into  the 
cavity  to  wash  away  the  broken-up  brain-substance. 

If  a  cranioclast  or  cephalotribe  is  at  hand,  it  should  now  be 
ap|)lied  and  the  head  carefully  extracted,  (^are  being  taken  to 
guard  the  shar[)  edges  of  the  cranial  bones  from  cutting  the 
maternal  tissues. 

When  the  crotchet  hook  is  used,  it  is  to  be  thrust  into  the 
skull  and  hooked  into  the  base  about  tlu;  forearm  nuignum. 
After  «)l)taining  a  firm  hold  the  head  is  drawn  down. 

When  long  scissors  are  employed  to  open  the  skull-cavity 
the  tips  of  the  blades  should  be  kept  between  the  two  Hngers 
of  the  operator's  left  hand  which  are  in  contact  with  the 
head.  The  cutting  is  done  by  little  snips,  separating  the 
blades  as  little  as  possible.  Having  cut  through  to  the  skull, 
the  tip  of  the  scissors  with  the  blades  closed  is  thrust  through 
a  fontanelle  or  suture.  The  blades  are  then  separated  as 
widely  as  possible  and  swept  about  to  break  up  the  brain- 
substance.  The  cerebral  cavity  is  washed  out  and  the  crotchet 
used  as  described. 

Sometimes  after  the  cranial  contents  have  been  removed 
the  child  is  expelled  by  natural  eflForts. 

In  most  cases  in  which  the  peb.  is  will  permit  of  their  proper 
application,  t'  rdinary  forceps  may  be  used  as  extractors  of 
the  i)erforate«'  nead. 

Perforation  of  the  after-coming  head :  When  it  is  necessary 
to  ])erforate  the  after-coming  head,  the  perforator  may  be  in- 
serted through  the  quadrilateral  fontanelle  behind  the  ear, 
or  into  the  foramen  magnum  through  the  mouth  of  the  child. 

Decapitation:  In  impacted  shoulder  presentation  it  may  be 


EMHRYOTOMY.  417 

necessary  to  sever  the  head  from  tlie  «rmil<  in  onh'r  to  efleet 
delivery. 

Tliis  may  he  perfornwd  hy  passin*;  the  hook  end  of  the 
'look  and  crotchet  over  th(!  neck  to  <h-aw  it  down  as  far  as 
possible,  where  it  is  held  hy  an  assistant.  IJy  means  of  a 
pairof  lon^r-liandlcd  scissors  the  operator  can  then  cut  throiin;h 
the  neck,  heinj^  careful  to  iruard  the  hlades  between  the  two 
fingers  of  the  left  hand  held  in  the  vagina. 

Evisceration:  This  is  rarely  indicated.  \\'hen  necessary  it 
may  be  done  with  a  j)air  of  long-handled  scissors. 

In  all  cases  after  the  separation  of  the  |)laeenta,  the  uterine 
cavity  should  be  douched  with  hot  salt  solution.  Lacerations 
of  the  soft  tissues  should  then  be  sought,  and  if  found  suturc.'d 
at  once. 

Dangers  of  embryotomy :  The  chief  dangers  of  embryotomy 
are,  lacerations  of  the  maternal  tissues  by  spicules  of  bone  or 
by  instruments;  and  sepsis. 

As  the  mother  has  !)een  exhausted  by  prolonged  and  in- 
effectual   efforts   to   comj)letc    labor,   before   embryotomy    is 
performed,   she  has   but  little  resisting  power  should  septic 
infection  take  place ;  while  the  bruised  and  lacerated  condi- 
^,  tion  of  the  soft  parts  favors  the  development  of  sepsis. 
27— Obst. 


INDEX. 


Induction  of  abor- 


A. 

Abortion,  191 
coiupk^tf,  l!)rt 
(lefiiiition,  UM 
(liaRnosis,  l!t7 
etiology,  1!M> 
oriuiii,  fu'tiil.  197 
iiiatcnial,  liKi 
pati'iiiiil.  l!M> 
fn'(HUMic,v,  !!•■") 
iiuluction   of  (see 

lion),  ;{7l 
iiiovitablc,  197 
missed,  'J('<1 
labor,  201 
partial,  19.S 
pathology,  19') 
blood-mole,  19(5 
cast-off  decidiia,  19(5 
effusion  of  blood,  196 
prognosis,  19rt 
symptoms,  19.") 
expulsion  of  the  ovum,  195 
homorrhage,  195 
pi.in,  195 
threatened,  197 
treatment,  198 
active,  aOO 
after-,  201 
expectant,  199 
of  inevitable,  199 
projjhylactic,  199 
of  threatened,  199 
tubal,  203 
Accidental  hemorrhage,  263 
apparent,  263 
concealed,  2(53 
etiology,  261 
symptoms,  264 
treatment,  265 
Albuminuria  in  pregnancy,  ISl 
Alimentary   system,   chaTiges    of, 

pregnancy,  43 
Allantois,  30 


in 


Amnion,  29,  35 
liijuor  aninii,  35 
function,  35 
I)ath()logy,  156 
dropsy,  15(5 
hydranmios,  156 
oligohydramnios,  156 
lircmature  rupture,  159 
sac,  30 
Amniotic  bands,  15H 
Anasarca  of  fo'tus,  166 
Anatomy,  obsti'tric  (see  Obstetric  atiat' 

omif),  5(5  !Ki 
Apojdexy  of  placenta,  162 
Area  pellucida,  2H 
Areolie,  abscess  of,  331 
Arrest  of  lactation,  331 
indications,  3:51 
method,  331 
Atresia  of  vagina,  302 
Axis  of  bony  outlet,  76 
of  brim,  76 
parturient,  76 
of  plane  of  the  vulvovaginal  ring, 

76 
relation  of  uterine  to  fcetal,  90 

B. 

Ballottcment,  50 
Bladder,  calculus,  303 
cvstocele,  303 
distended,  303 
Blastodermic  vesicle,  26 
Blood-mole,  196 
Bloodvessels  in  pregnancy,  184 
Breasts,  abscess  (see  Mammary  abscess), 
329 
absence,  320 

changes  in  pregnancy,  41 
diseases  of,  172 
abscess,  172 

eczema  of  the  nipples,  172 
excessive  secretion,  172 
engorgement  of,  322 

419 


420 


INDEX. 


Breasts,  engorgement  of,  treatment, 

breast-handiigi',  ;{24 

breaat-i)uniii,  ',VZ2 

massage,  '.V2'i 

Murphy  binder,  324 

nursing,  ;}2'-i 
hypertrophy,  320 
inflammation  of  (see  Mastitis),  326 
mastitis  (see  Mastitis),  32(i 
supernumerary,  320 

c. 

Csesarean  section,  404 
liistory,  404 
indications,  404 
operation,  406 
Porro,  408 
Calculus  of  bladder,  303 
Caput  succedaiM'um,  115 
'*,  rcinonia  of  cervix,  303 
Cardiac  diseases  in  i)regnancy,  184 
Cerebral  hemorrhage  in  puerperium, 

338 
Cervical  lacerations,  repair,  370 

operation,  370 
Cervix,  atresia,  298 
carcinoma,  303 
cicatricial  contraction,  298 
impaction  of  anterior  lip,  299 
polypi,  305 
rigidity,  298 

treatment,  298 
softening  of,  41,  46 
violet  discoloration,  41,  47 
Chorion,  30,  31,  34 
hydatid i  form  degeneration,  159 
pathology,  159 
villi,  31, ''<2 
Circulatory    system,    changes    of,  in 

pregnancy,  43 
Climacteric,  18 
Ccelum,  29 
Colostrum,  149 
Conception,  21 

Constipation  in  pregnancy,  174 
Cord  (see  UmhiUcal  cord),  30,  34 
Corpus  luteum,  20 

of  pregnancy,  20 
Cough  in  pregnancy,  183 
Cutaneous     system,    changes    of,    in 

l)regnancy.  44 
Cystitis  in  puerperium,  336 
Cystocele,  303 


D. 


Decidua,  23,  34 


Decidua,  cells,  25 
coalescence,  23 
development  of,  23 
layers,  23 
pathology,  154 
atrophy, 156 

decidual  endometritis,  154,  155 
acute,  154 
etiology,  154 
treatment,  154 
chronic,  155 
catarrhal,  155 
difl'use,  155 
occurrence,  155 
treatment,  155 
reflexa,  23 
serotina,  23 
vera,  23 
Dental  caries  in  pregnancy,  173 
Development,  23 
decidua  (see  Decidua),  23 
f(Btus  (see  r^etiis),  25 
l)lacenta  (see  Placenta),  3 
Diagnosis  of  pregnancy,  45-51 
Diarrhreu  in  pregnancy,  174 
Diphtheria  in  puerperium,  333 
Ductus  arteriosus,  38 

venosus,  36 
Dyspnoea  in  pregnancy,  183 
Dystocia,  209 
due  to  abnormalities  of  the  foetal 
appendages,  253 
accidental     hemorrhage, 

263 
adherent  placenta,  266 
coiling     of    cord     about 

neck,  258 
placenta  prsevia  (sec  Pla- 
centa prievia),  258 
prolapse  of  cord,  254 
retained  placenta,  266 
short  cord,  253 
anomalies  of  foetal  development, 
248 
encephalocele,  252 
hydrencephalus,  252 
hydrocei)halus,  250 
meningocele,  252 
monstrosities,  253 
overgrowth  of  foetus,  248 
premature  ossification  of 

skull,  249 
tumors  of   foetal   trunk, 
252 
malpositions  of  the  foetus,  209 
breech  presentations,  221- 

237 
brow  presentations,  221 


INDEX. 


421 


Dystocia,  due  to  malpositions  of  tlie 
foitus,  face  presentations, 
21o-^'21 
occipitoposterior  cases,  209- 

214 
plural  births,  245 
prolapse  of  the  foetal  limbs, 

244 
transverse      presentations, 

237-244 
triplets,  248 
twin  labors,  245 
maternal,  2G8-;J12 
anomalies  in  forces  of  labor,  268- 

of  the  maternal  soft  structures 
(see  Uterus,  Vagina,  etc.),  297- 
;J12 

of  the  pelvis  (see  Pelvis),  272- 
297 

E. 

Eclampsia,  188 
course,  190 
definition,  188 
diagnosis,  192 
eclamptic  fit,  189 
duration,  189 
etiology,  190 

toxaemia,  190 
frequency,  188 
pathological  anatomy,  191 
kidneys,  191 
liver,  192 
lungs,  192 
spleen,  192 
prognosis,  192 
symptoms,  188 

premonitory,  188 
termination,  190 
treatment,  192 
during  attack,  193 
medical,  193 
obstetrical,  194 
prophylactic,  192 
urine,  188 
Ectoderm,  28 
Ectopic  gestation,  202 
definition,  202 
diagnosis,  206 
etiology,  204 
frequency,  202 
pathology,  204 
primary,  202 
secondary,  202 

tubal,  "infundibular,  202 
interstitial,  202 


Ectopic    gestation,   seco)idary    (ubal. 
true,  202 
tubo-ovarian,  202 
symptoms,  205 
terminations,  202,  203 
treatment,  207 
varieties,  202 
abdominal,  202 
ovarian,  202 
tubal,  202 
Eczema  of  nipples,  172 
Elephantiasis  of  fa'tus,  165 
Embryology,  21 
Embryonic  area,  28 
Embryotomy,  411 
dangers  of,  417 
definition,  411 
eviscerat^-.a,  417 
indications,  411 
instruments,  411 
basiotribe,  413 

blunt-pointed  scissors,  415,  416 
Braun's  hook,  414 
cephalotribe,  413,  416 
craniodast,  412,  416 
hook  and  crotchet,  413,  416 
perforators,  412,  416 
operation,  415 
perforation  of  after-coming  head, 
416 
Encephalocele,  252 
Endocervicitis,  172 
Endometritis,  decidual,  acute,  154 
chronic,  155 
in  puerperal  septic  infection,  347, 350 
Entoderm,  28 
Epiblast,  26,  28 
permanent,  28 
primitive,  28 
Episiotomy,  361 
advantage  Ci,  362 
definition,  361 
indications,  361 
operation,  362 
Erysipelas  in  puerperium,  333 
Erythema  in  puerperium,  333 
Eutocia,  96,  209 

F. 

Fibromyoma  of  uterus,  304 
Foetal  circulation,  36 

head,  flexion  of,  85,  108,  109 

moulding  of,  Hti 
heart-sounds,  132 
movements,  96 
trunk,  88 
diameters,  88 


422 


INDEX. 


Fd'tal  trunk.  mol)ility,  88,  89 
Fd'tus,  iiiiasartii,  l()(i 
aiioiiialifs,  Ki") 
centre  ()f  gravity,  !»(> 
circulation  (sec  Fn'tol  circulation),  3(i 
contagious  diseases,  1G8 
death  of,  1()8 

causes,  168 

se()uela!,  169 
development,  25 
elephantiasis,  165 
head  of,  77 

l»ase,  77 

diameters,  82-84 

flexion  of,  85 

Klahella,  81 
nobility  of,  88,  89 

mouldinji  of,  86 

occiput,  81 

planes,  85 

circnmfereucos,  85 

protuberances,  81 
frontal,  82 
occipital,  81 

sinciput,  81 

vault,  77 
fontanelles,  78 

false,  80 
sutures,  78 

vertex,  80 
ichthyosis,  166 
mature,  76 
monstrosities,  iS5 
mortality  of,  165 
ossification  of  skull,  249 
overgrowth,  2  ts 

treatment,  249 
positions  (see  Positions),  93 
posture,  89 

normal,  89 
presentations  (see  Presentations),  91 
rachitis,  166 

shape  relative  to  uterus,  96 
syi)hilis,  167 

diagnosis,  i67 

infection,  167 

manifestations.  167 

treatment,  168 
tuberculosis,  168 
tumors  of  trunk,  252 
Fontanelles.  78 

false,  80 
Forceps,  axi.s-traction,  377 
description,  375 
operation,  371 

ill  breech  cases,  390 

dangers  of.  391 

iu  dorsal  position,  381 


Forceps  operation  in  dorsal   )>ositi(m, 
axis-trai^ion,  377,  3'^.3 
with  ordinary  forcejis,  3H() 
distention  of  iicrincuiii,  .{H.'J 
extraction.  "!  ".* 
introduction  of  blades,  .381 
support  of  liml)s.  3f^l 
in  face  jiresentations,  390 
high,  37(i,  381 
history,  374 
indications  for.  378 
iu  left  lateral  position,  extraction, 
388 
insertion  of  blades,  386 
low,  37(),  381 
medinin,  381 
methods,  380 
Continental,  .380 
English,  380 
in  occipitojiosterior  cases  389 
jHisture  of  patient,  380 
pr(^paratioiis  for,  379  , 

Funic  souffle,  133 

G. 

(lalactocele,  3.31 
(ralact(>rrh(ea,  322 
(ringivitis  in  preijiiancy,  173 
Graafian  follicle,  is 

membrana  granulosa,  18 

number,  18 

ovum  (see  Ovum),  18,  19 

tunica  fibrosa,  18 
propria,  18 

H. 

HaMiiatoma  of  vagina,  302 
Htematnria  in  pregnancy,  180 

in  ])uerj>erium,  337 
Heart  inurmurs  in  pregnancy,  184 
Hegar's  sign,  48 

Hemorrhage,  accidental  {see  Accidental 
hemorrhafie),  263 
hsematoina,  317 
post-partum,  312 
definition,  312 
diagnosis,  313 
etiology,  312 
symptoms,  313 
treatment,  314-316 
puerperal,  317 
secondary,  315 
Hemorrhoids  in  pregnancy,  180 

in  puerperiuni,  3.35 
Hernia  into  umbilical  cord,  165 
Herpes  in  pregnancy,  187 


INDEX. 


42;i 


Hydniimiios,  I'lfi 

diaj;ii()sis,  ir>7 

fti()l(i;;y,  lot) 

syniptdins,  laT 

troatiiKiit,  l.")!-i 
Ilydroi-eiilialus.  250,  252 
llvnicu,  unruiitmi'd,  ;}02 
Hypoblast,  2fi,  2.S 

cleavajri',  2H 

permanent,  21) 

I. 

Iclithyosis  of  fo'tus,  Kifi 
Icterus  in  iJrt'fjnant-y,  179 
Iinpetifjo  in  prctrnancy,  187 
lni])rcgnation,  21 
Indigestion  in  pregnaney,  174 
Induction  of  abortion,  371 
definition,  371 
indieations,  371 
methods,  372 

dilatation  and  curetting,  372 
drugs,  372 
of  premature  labor,  373 
indieations,  373 
methods,  374 
Krause's,  374 
Tarnier's.  374 
Infectious  diseases  in  pregnancy,  187 
Insanity  in  puerperiuni,  33S-341 
Inversion  of  uterus,  310-312 

K. 

K  Kluey  of  pregnancy, 181 

Labor,  delayed,  270 
causes,  270 
diagnosis,  270 
treatment,  271 
missed,  201 

normal  (see  Normal  Inbor),  96 
pathology  (see  Dystocia),  209-212 
precipitate,  268 
etiology,  268 
treatment.  269 
premature,  induction  of  (see  Induc- 
tion of  premature  labor).  373 
Lacerations    of    cervix    (see    Cervical 
lareratioii.s),  370 
of  perineum  (see  Perineal  lacerations), 
362 
Lactation,  148 

arrest  of  (see  Arrest  of  lactation),  331 
colostrum  (see  Colostrnm),  149 


Lactation,  establishment  of,  150,  151 

nianmiarv  glands,  1 19 

milk  (see  Milk],  149 
Lcucorrlnea  of  vagina,  169 
Li(iuoraninii,  alterations  in  character, 

15i» 
Lochia,  146 

alba,  146 

character.  146 

composition,  146 

odor,  146 

(juantitv,  146 

rubra,  146 

serosa,  146 

M. 

Malaria  in  i)uerperium,  334 
Maniniie  (see  Jireasl.t),  .320 
Mammar.v  abscess,  .329 
of  areola',  331 
location,  329 
sympl(»ms.  329 
treatment.  329 
incision,  330 
Mastitis,  32() 
etiology,  327 
symptoms,  327 
treatment,  328 
abortive,  328 
varit^ties,  326 
glandular,  326 
parenchymatous,  326 
])ost-maniniar.v,  326 
subcutaneous,  326 
Measles  in  puerperium,  .332 
Membranes,  29 
rupture  of,  1.36 
at  term.  33 
Meningocele,  2.52 
Menopause,  18 
Menstruation.  17,  20 
cause.  17 
cessation.  18 
character  of  flow,  17 
duration,  18 
onset,  17 

and  ovulation,  20 
quantity,  18 
structural  changes,  17 
suppression,  45 
Mesoblast,  29 
cleavage,  29 
Mesoderm,  29 
Milk,  149 
chemical  composition,  149 
quality,  150 
quantity,  150 


424 


INDEX. 


Milk,  secretion  of,  150 
deficient,  :J-JO 
excessive,  .'Wl 
giilactonho'a,  .322 
polygalactia,  321 
Miscarriage   (see   Abortion),   194,  195, 

201 
Mole,  blood-,  196 
fleshy,  155,  196 
tubal,  203 
vesicular,  159 
symittoms,  159 
treatment,  161 
Monstrosities,  253 
Multipara,  97 
Myelitis  in  puerperium,  337 

Nephritis  in  pregnancy,  182 
Nervous  system,  changes  of,  iu  preg- 
nancy, 43 
Neuralgia  iu  pregnancy,  185 
Neuritis  in  puerperium,  337 
Neuroses  in  pregnancy,  185, 186 
Nipples,  anomalies,  320 
inversion,  320 
sore,  325 

treatment,  325 
supernumerary,  320 
Normal  labor,  96 

antesthetics,  use  of,  126,  127 
antisepsis,  119 
agents,  120 
nurse,  122 
obstetrician,  121 
patient,  123 
blood  lost  iu,  118 
duration,  97 
first  stage,  102 

anatomy  of  soft  parts,  107 
clinical  phenomena,  106 
initial  labor-pains,  106 
reflex  vomiting,  107 
dry  labors,  105 
management,  12H 
examination,  129 
auscultation,  132 
palpation,  129 
vaginal,  134 
preliminary  cond  uct  of  phy- 
sician, 128 
succeeding     the    examina- 
tion, 136 
mechanism,  103 
action  of  uterine  fibres,  104 
dilatation  of  cervix,  103 
hydrostatic  pressure,  103 


Normal  labor,  first  stage,  os  uteri,  106 
rupture  of  membranes,  105 
signs  and  symptoms,  102,  103 
characteristic,  103 
premonitory,  102 
forces  of,  99 
contractions  of  abdominal  mus- 
cles, 101 
of  uterus,  99 
duration,  99 
effect  of,  100 
intermittent,  99 
involuntarv,  99 
painful,  99' 
peristaltic,  99 
of  vaginal   and   pelvic  mus- 
cles, 99,  101 
gravity,  102 
polarity,  100 
retraction  of  uterus,  100 
management  of,  119 
onset,  causes  of,  97,  98 
preparation  for,  124 
nurse,  126 
patituit,  125 

labor-room,  125 
physician,  124 
obstetric  bag,  124 
second  stage,  107 
anatomy,  115 
clinical  phenomena,  113 

moulding  of  head,  114 
management,  137 

laceration  of  perineum,  138 
perineal  stage,  137 
position,  137 
rapid  cases,  137 
mechanism,  107 
delivery  of  trunk,  113 
head  movements,  108 
descent,  108 
extension,  112 
external  rotation,  112 
flexion,  108,  109 
internal  rotation,  110 
restitution,  112 
stages,  97 
third  stage,  116 

management,  141 

Crede's   method  of  expres- 
sion, 141 
final  measures,  142 
lacerations,  141 
retraction  of  uterus,  142 
mechanism,  116 

expulsion  of  placenta,  117 
separation  of  placenta,  110 
of  membranes,  117 


INDEX. 


4-2.' 


O. 

Obstetric  anatomy,  r)<)-96 
operations,  ;it)l-417 
Ciesarean  section,  404-409 
embryotomy,  411-417 
episiotomy,  3()1 
forceps,  374-391 
general  rules  governing  selection 

of,  409-411 
induction  of  abortion,  371 
of  premature  labor,  373 
repair  of  cervical  lacerations,  370 
complete  tear,  3(W 
external  superficial  tear,  3G3 
internal  tear,  361 
vaginal    and    perineal     lacera- 
tions, 362 
symphysiotomy,  398-404 
versions,  391-398 
(Edema  of  placenta,  164 
of  vagina,  169 
of  vulva,  169 
Oligohydramnois,  156 
Ovarian  cysts,  306 
Ovulation,  18,  20 

and  menstruation,  20 
Ovum,  18,  19 
at  different  periods  of  pregnancy, 

35,  36 
discus  proligerus,  18 
fertilization,  22 
germinal  spot,  19 

vesicle,  19 
immature,  19 
impregnated,  25 
maturity,  19 
nucleolus,  19,  26 
nucleus,  19,  25 
polar  bodies,  19 
pronucleus,  19,  26 
segmentation,  26 
yolk,  19,  25 
zona  pellucida,  19 

P. 

Parametritis  in   puerperal  septic  in- 
fection, 350 

Parotitis  in  pregnancy,  173 

Parturient  axis,  76 

Parturition,  57 

Pathology  of  amnion  (see  Amnion),  156 
of  breasts  (see  Breasts),  172 
of  chorion  (see  Chorion),  159 
of  decidua  (see  Decidua),  154 
of  foetus  (see  Foetus),  165 
of  placenta  (see  Placenta),  161 
of  pregnancy, 154 


Pathology   of   the   pregnant   woman, 
169 
abortion  (see  Abortion),  194 
albuminuria,  IMI 
bloodvessels,  184 
cardiac  diseases,  184 
constipation,  174 
co'igh,  183 
dental  caries,  173 
diarrhoea,  174 
dysi>ntea,  183 

eclampsia  (see  Eclampsia),  188 
ectopic    gestation    (see    Ectopic 

(jesttttiou),  202 
gingivitis,  173 
hiematuria,  180 
iieart  murmurs,  184 
hemorrhoids,  180 
herpes,  187 
icterus,  179 
impetigo,  187 
indigestion,  174 
infectious  diseases,  187 
kidney  of  pregnancy,  181 
nephritis,  182 
acute,  182 
chronic,  182 

difierential  diagnosis,  182 
treatment,  182 
neuralgia,  185 
neuroses,  185,  186 
parotitis,  173 
phthisis  pulmonalis,  183 
pigmentation,  187 
pneumonia,  1H3 
premature  labor  (see  Premature 

labor),  194 
ptyalisni,  173 
salivation,  173 
scanty  urine,  180 
thyroid  gland,  185 
toxaemia  (see  Toxaemia),  188 
vomiting,  174 
perniciou?!  (see  Pernicious  vom- 

itina),  175 
simple,  175 
of   umbilical    cord     (see    Umbilical 

cord),  164 
of  uterus  (see  JHerus),  170 
of  vagina  (see  Vagina),  169 
of  vulva  (see  Vulva),  169 
Pelvic  canal,  soft  parts,  71-76 
muscles,  71-74 
floor,  72 
fascia,  74 
measurement,  72 
muscles,  71-74 
segments,  72 


426 


INDEX. 


Pelvio  floor,  segments,  pubic,  72 

sacral,  72 
Pt'lvi-p'iiitu)  canal,  57,  (il 
I'dvinictry,  275 

nicHsiirenu'Uts,  275-279 
external,  275 
internal,  277 
Pelvis,  (il 
anomalies  of,  272-207 
classification,  27.'} 
(leei),  2ri2 
diagnosis,  274 

due  to   injuries,  tumors,  or   dis- 
ease, 291 
spinal  curvature,  29() 
kyphoscoliosis,  297 
kyphosis,  290 
lordosis,  290 
scoliosis,  297 
flat,  283 

mechanism  of  labor,  287 
non-rachitic,  283 
rachitic,  285 
treatment  of  labor,  288 
frequency,  272 
funnel-shai)ed,  282 
justomajor.  279 
justominor,  279 
mulacosteon.  291 
inasc\iline,  282 
obliquely  cor.tracted,  289 
pseudomalacosteon,  292 
shallow,  282 

s])ondylolisthetic  pelves,  293 
transversely  contracted,  291 
diameters,  67-70 
of  the  brim.  07-70 
conjugate,  08 
measurements,  70 
oblique,  70 
transverse,  70 
false.  03 
inclination,  71 
joints  of,  02 

mobility,  03 
lateral  grooves,  05,  06 
planes,  00 
the  brim,  00 
the  cavity,  07 
the  outlet,  07 
true,  03 
cavity,  04 

boundaries,  04-60 
inferior  strait,  64 
inlet,  03 
outlet,  04 
superior  strait,  03 
Perineal  body,  75 


Perineal    lacerations,   complete    (ear 
:{()8 
conditions,  308 
operation,  3(i8-370 
external  tear,  303 
internal  tear,  304 
conditions,  304 
method  of  repair,  305  308 
repair,  3()2 
Perineum,  75 

rigidity,  302 
Peritonitis  in  puerperal  septic  iiilVc 

tion,  351 
Pernicious  vomiting,  175 
duration,  175 
etiology,  170 
physiological    uterine    contrac 

tions,  17() 
prcdisjxising  causes,  176 
symptoms,  175 
treatment,  178  ., 

dietetic,  178 

digital  dilatation  of  cervix,  179 
drugs,  179 
hygienic,  178 
induction  of  abortion,  179 
rectal  alimentation,  178 
Phlegmasia  alba  dolens.  351 
Phthisis  pnlmonalis  in  pregnancy,  183 
Pigmentation  in  pregnancy,  50,  187 
Placenta,  31 
adherent,  164,  266 
(;auses,  207 
treatment,  208 
anomalies,  101 
of  position,  101 
of  shape,  101 
of  size,  101 
of  weight,  161 
apoplexy,  102 
causes,  103 
definition,  102 
forms,  102 
results,  103 
symptoms,  103 
treatment,  103 
as[)ects,  33 
battle-dore,  161 
circular  sinus,  34 
cotyledons,  33 
degeneration,  calcareous,  162 

fatty,  162 
functions,  34 
horse-shoe,  101 

inflammation  (see  Placentitis),  163 
intervillous  spaces,  32 
nniternal  blood,  33  , 

tuembranacea,  161 


INDEX. 


12: 


Placenta,  CBclema  of,  164 
])olyi)i,  19(i 
1  lie  via,  258 
centralis,  258 
etiology,  259 
lateralis,  258 
marginalis,  258 
symptoms,  2G0 
treatment,  261 
premature  separation  of  (see  Acci- 
dental hemorrhage),  263 
retained,  266 
sinuses,  32 
site,  34 
structure,  31 
succenturiata,  161 
syphilis  of,  164 
at  term,  33 
tumors  of,  16\ 
white  infarctions,  162 
Placentitis,  163 

pathological  changes,  163 
Plural  hirths,  245 
Pneumonia  in  pregnancy,  183 

in  ])ueri>eriuni,  333 
Polygalactia,  321 
Polypi  of  cervix,  305 

of  placenta,  196 
Porro  operation,  408 
Position,  92 
Positions,  93-96 
breech,  95 
face,  94 

occipitoposterior,  209 
diagnosis,  209 
management  of  labor,  212 
at  the  pelvic  inlet,  213 
in  the  pelvic  cavity,  214 
mechanism,  210 
abnormal,  211 
prognosis,  214 
somatic,  95 
vertex,  94 
Pregnancy,  ballottement,  50 
changes  in  alimentary  system,  43 
circulatory  system,  43 
cutaneous  system,  44 
maternal  organism,  38 

uterus,  38 
nervous  system.  43 
respiratory  system,  43 
urinary  system.  44 
corpus  luteum  of,  20 
diagnosis,  45-51 
differential,  52,  53 
of  life  or  death  of  child,  54 
of  nulliparity,  53 
of  parity,  53 


Pregnancy,  diagnosis,  saniuiary  of,  .")! 
triiiR'sters,  45-51 
first,  4.5-48 
objective  signs,  4<i 
ilegar's  sign,  48 
softening  of  cervix,  46 
violet  discoloration,  47 
symptoms,  45 

mammary  changes,  46 
nausea,  46 

suppression    of    menstrua- 
tion, 45 
vomiting,  46 
second,  48 

objective  signs,  49 
symptoms,  48 
third,  .50 
objective  signs,  51 
symptoms,  .50 
duration,  44 

(■(inimon  rule,  44 
date  of  quickening,  45 
table,  45 
fu'tal  heart-sounds,  49 

movements,  49,  51 
Hegar's  sign,  48 
hygiene  of,  .54-.56 
likely  to  occur,  22 
lineai  albicantes,  44,  .51 
management  of,  54-56 
normal,  21 

pathology  of  (see  Pathology  of  preg- 
nancy), 154 
pigmentation,  42,  44,  .50 
pressure-symptoms,  51 
quickening,  49 
"settling,"  51 
uterine  contnictions,  49 

souffle,  49 
vomiting  of,  43 
Premature   labor   (see   Abortion),  194. 
i  201 

Presentation,  90 
Presentations,  91 
breech,  221 
causes,  222 
diagnosis,  223 
frequency,  222 
management,  226 
arms  delivered,  head  retained, 

234 
arrest  at  brim,  228 
delivery  of  after-coming  head, 

233 
impaction  in  pelvis,  230 
rapid  extraction  of  trunk,  230 
mechanism,  224 
abnormal,  225 


428 


INDEX. 


rrcsciitations,  cephalic,  91,  92,  90 
face,  95,  'Jir> 
caiis'-s,  Jilfj 
(liaKOosiK,  2\Ty 
nianageinent,  219 
niechaiiisni,  217 
occurrence,  215 
positions,  215 
peivi(\  91,9;i 
shoulder,  95 
somatic,  91,  93 
transverse,  92,  237 
causes,  2.'i7 
diagnosis,  238 
fretjuency,  237 
iiechanisiu,  239 
spontaneous  evolution,  240 

version,  239 
with  body  doubled  up,  240 
positions,  237 

dorso-anterior,  237 
dorsoposterior,  237 
Primigravida,  97 
Primipara,  97 
Primitive  groove,  28 

streak,  28 
Prolapse  of  cord,  254 
of  fietal  limbs,  244,  245 
of  uterus,  172,  300 
Pruritus  of  vagina,  169 

of  vulva,  1(59 
Ptyalism,  173 

in  pregnancy,  173 
Puerperal  period  (see  Puerperal  state), 
143 
pathology  of  (see  Uterus,  Breasts, 
Hemorrhage),  312 
state,  143 
anatomy  of  parts,  143 
bladder,  144 
broad  ligaments,  144 
peritoneum,  144 
uterus,  143 
vagina,  144 
vulva,  144 
beginning,  143 
duration,  143 
management  of,  150 
after-pains,  153 
care  of  breasts,  151 
of  genitalia,  151 
contraindications   to   suckling, 

152 
lying-in  room,  150 
nourishment,  152 
rest,  152 
physiological  phenomena,  143 
physiology  of,  145 


I'uerperal  state,  jUiysiology  of,  invo- 
lution, 145 

abdominal  walls,  147 

circulatory  system,  147 

digestive  api>aratus,  148 

lactation  (see  Lactation),  148 

ovaries,  147 

pelvic  joints,  147 

skin,  148 

tubes,  147 

urinary  system,  147 

uterus,  145 
lochia  (see  Lochia),  146 
mucosa,  Mfi 
muscle-cells,  145 
vessels  and  nerves,  145 

vagina,  147 

vulva,  147 
septic  infection,  345-361 
bacteriology,  345 

cervix,  346  ^ 

saprsemia,  346 

vagina,  346 
definition,  345 
diagnosis,  354 

culture  from  uterus,  355 

lochia,  354 
fretjuency,  345 
pathology,  347 

auto-infection,  352 

endometritis.  347 

modes  of  infection,  351 

parametritis,  350 

peritonitis,  351 

phlegmasia  alba  dolens,  351 

pyaemia,  351 

salpingitis,  350 

ulcer,  347 

vaginitis,  347 
symptomatology,  352 

onset,  352 

param(>tritis,  353 

peritonitis,  353 

pyaemia,  353 

septicaemia,  354 
treatment,  357 

general,  359 
serum-therapy,  360 

local,  357 

prophylaxis,  357 
Piierperium  (see  Puerperal  state),  143 
fever  other  than  septic,  343,  344 
intercurrent  diseases,  332-361 
anaemia,  334 

cerebral  hemorrhage,  338 
cystitis,  336 
diphtheria,  333 
erysipelas,  333 


INDEX. 


429 


Piicrpcriiiin,     intcrrnrront     diseasos, 
I'rytliL'ina,  :{■'{:{ 
liiciiiatiiria,  WM 
hemorrhoids,  ;{:>i> 
iiicontinciu'o  of  uriue,  ;53() 
insanity,  :{:5rt-341 
malaria,  334 
muscles,  33'i 
myelitis,  337 
neuritis,  337 
pneumonia,  333 
pyelonephritis,  336 
retention  of  urine,  335 
rh(iuniatism,  333 
rotheln,  333 
scarlet  fever,  332 
septic  infection  (see  Puerperal  septic 

infection),  345 
sudden  death,  341 

entrance  of  air  into  uterine  si- 
nuses, 343 
pulmonary  embolism,  341 
thrombosis,  341 
Pyaemia  in  puerperal  septic  infection, 

351 
Pyelonephritis  in  puerperium,  33t> 


Q. 

Quickening  of  pregnancy,  49 


B. 

Rachitis  of  foetus,  16fi 

Respiratory   system,   changes    of,    in 

pregnancy,  43 
Retroversion  of  uterus,  170 
Rheumatism  in  puerperium,  333 
Rotheln  in  puerperium,  333 
Rupture  of  uterus,  306 


S. 

Salivation,  173 

Salpingitis  in  puerperal  septic  infec- 
tion, 350 
Scarlet  fever  in  puerperium,  332 
Segmentation,  26 

morula  stage,  26 
Semen,  21 
Somatopleure,  29 
Spermatozoids,  21 

meeting-place  with  ovum,  22 
Splanchnopleure,  29 
Subinvolution,  318 
Symphysiotomy,  398 

dangers  of,  403 


Symphysiotomy,  definition,  398 

French  method,  402 

history,  39.H 

indications,  ;'>99 

Italian  method,  400 

rationale,  399 
Syi)iiilisof  fo'tus,  167 

of  placenta,  164 

T. 

Thyroid  gland  in  pregnancy,  185 
Toxiemia  (sec  Kcliinipsifi),  1H8 
Treatment  of  abortion,  19rt 

of  accidental  heniorriiagi',  2(i5 

of  adherent  placenta,  268 

of  apoplexy  of  placenta,  163 

of  decidual  endometritis,  acute,  154 
chronic,  155 

of  delayed  labor,  271 

of  eclampsia,  192 

of  ectopic  gestation,  207 

of  engorgement  of  breasts,  322 

of  mammary  abscess,  329 

of  mastitis,  328 

of  nephritis  in  pregnancy,  182 

of  overgrowth  of  feet  us,  249 

of  pernicious  vomiting,  178 

of  ]»ost-partuni  hemorrhage,  314-316 

of  precipitate  labor,  269 

of  prolai)sc  of  umbilical  cord,  255 

of  i)uerperal  septic  infection,  357 

of  retroversion  of  uterus,  171 

of  rigidity  of  cervix,  298 

of  rupture  of  uterus,  309 

of  sore  nipples,  325 

of  subinvolution  of  uterus,  319 

of  syphilis  of  fretus,  168 

of  vesicular  mole,  161 
Triplets,  248 
Tubal  mole,  203 
Tuberculosis  of  ftctus,  168 
Tumors  of  placenta,  164 

of  uterus,  172,  304-306 
Twin  labors,  245 

complications,  247 

u. 

Ulcer   in  puerperal  septic  infection, 

347 
Umbilical  cord,  30,  34 
anomalies,  164 
coils,  164 
knots,  165 
of  length,  164 
coiling  about  fcetal  neck,  258 
hernia  into,  165 


430 


INDEX. 


Uniliilical  cord,  prolapse  of,  251 
diagnosis,  255 
treatment,  255 
sliort,  25U 
vein,  ;{({ 
UracliiiH,  30 

Urinary  system,  cliangcs  of,  in  preg- 
nancy, 44 
Urine,  incontinence  of,  in  pncrperinm, 

retention  of,  in  pnerperinm,  335 
scanty,  in  pregnancy,  IHO 
Uterine  l)ruit,  133 
contractions  in  pregnancy,  49 
inertia,  270 

sonffle  of  pregnancy,  49 
Utcrns,  arteries  of,  39 
cavity  of,  57 

cliangcs  from  jircgnancy,  38 
contractions,  40,  99 
dextro-rotation,  41 

diagnosis,  171 
displacements  of,  299-302 
double,  297 
endocervicitis,  172 
fibrorayoma,  304 
full-term,    relation     to    contiguous 

structures,  GO 
inversion,  310-312 
ligaments,  59 
lymphatics,  39 
n'lusclc-fibres,  39,  57 

layers  of,  57-59 
nerves,  40 
peritoneum,  60 
prolapse,  172,  300 

relation    to    pelvis    and    abdo."oen, 
fourth  month,  40 
ninth  month,  40 
seventh  month,  40 
sixth  month,  40 
third  month,  40 
retroversion,  170 

anatomical  results,  170 
causation,  170 
treatment,  171 
mild  cases,  171 
severe  cases,  171 
rupture  of,  306 
etiology,  306 
site,  307 
symptoms,  308 
treatment,  309 
segments  of,  59,  100 
lower,  59 
upper,  59 


Uterus,  septate,  2f)7 
subinvolution,  318 

diagnosis,  319 

etiology,  318 

treatment,  319 
tumors,  172,  304-306 
walls  of,  57 

V. 

Vagina,  atresia,  302 
luematoina,  302 

lacerations  of  (see  Perineal  lacera- 
tions), 362 
leucorrlKea,  169 
oulema,  169 
pruritus,  169 
septa,  302 
varices,  469 

violet  discoloration,  41,  47 
Vaginitis  in   puerperal    septic   infec- 
tion, 347 
Varices  of  vagina,  169 

of  vulva,  169 
Vegetations  of  vulv.',  170 
Version,  spontaneous,  239 
Versions,  391 
definition,  391 
methods,  392 
bipolar,  393 
indications,  394 
method,  394 
external,  392 
indications,  393 
method,  393 
internal,  395 
indications,  395 
method,  396 
varieties,  391 
cephalic,  392 
pelvic,  392 
podalic,  392 
Vesicular  mole,  159 
Vitellus,  25 

Vomiting  of  pregnancy,  43, 46, 174, 175 
Vulva,  oedema,  169 
pruritus,  169 
varices,  169 
vegetations,  170 

w. 

Wharton's  jelly,  34 


Y. 


Yolk-sac,  30 


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VENTION AND  TREATMENT.  In  one  12mo.  volume  of  127  pages, 
with  9  illustrations.     Cloth,  $1.25. 

BERGMANN'S  SURGERY.     See  nni  />'r;v/wu»//,  page  30. 

BlLililNGS  (JOHN  S.).  THE  NATIONAL  MEDICAL  DICTIONAR'"^ 
Including  in  one  alphabet  English,  French,  German,  Italian  ana 
Latin  Technical  Terms  used  in  Medicine  and  the  Collateral  Sciences. 
In  two  octavo  volumes  containing  1574  pages  and  two  colored  plates. 
Per  volume,  cloth,  $6  ;  kither,  .$7. 

BLACK  (D.  CAMPBELL.).      THE    URINE    IN    HEALTH    AND 

DISEASE.  AND  URINARY   ANALYSIS,  PHYSIOLOGICALLY 

AND  PATHOLOGICALLY  CONSIDERED.     In  one  12mo.  volume 

of  256  pages,  with  7.S  engravings.     Cloth,  $2.75. 

A  concise,  yet  complete  manual,    tical  and  clinical  standpoint. —  The 

treating  of  the  subject  from  a  prac-    Ohio  Medical  JourvnL 

BLOXAM  (C.  L.).  CHEMISTRY,  INORGANIC  AND  ORGANIC. 
With  Experiments.  New  American  from  the  fifth  London  edition. 
In  one  handsome  octavo  volume  of  727  pages,  with  292  illustrations. 
Cloth,  $2;  leather,  $3. 

brewf:r  (geor(;e  e.).  atext-hook  of  the  principles 

AND  practice  OF  SURGERY.  Octavo,  7(iO  pages,  2S0  engrav- 
ings, 7  colored  plates.  Cloth,  $4;  leather,  S;"),  iiet ;  half  Morocco, 
•So. 50,  net.'    Just  read;/. 

This  volume  presents  the  essential  heartily  commend  the  book  not  only 
fact.s  of  surgery  in  a  comprehensive,  to  students  but  also  to  practitioners, 
clear  and  concise  manner.  The  book  — St.  Paid  Medical . I oiirmd. 
is  a  scientitic  exposition  of  modern  The  author's  intensely  itractical 
surgery,  and  the  reviewer  has  no  treatment  of  this  coniprehensi\e  suli- 
hesitancy  in  saying  that  it  is  (he  Jeet,  combined  with  brevity  and 
best  surgical  text-book  in  j)rint  by  definite  clearness  of  statement,  at 
an  American  author.  The  author  once  compels  the  reader's  attention 
presents  a  practical,  common-sense  |  and  bespeaks  the  success  of  the  work, 
and  yet  highly  scientific  work.     We  i  — Medical  Review  of  Reriewx. 

BRUCE  (J.  MITCHELL).  MATERIA  MEDICA  AND  THERA- 
PEUTICS. Sixth  edition.  In  one  12mo.  volume  of  600  pages. 
Cloth,  $1.50,  net.    See  Student's  Seriet  of  Manualt,  page  27. 


known    and    appreciated. — Medical 
Reriew  of  Reviews. 


This  new  edition  increases  the 
value  and  more  firmly  establishes 
the  reputation   of   a  work   already 

BRUCE   (.1.  .■>!  IT(^HELL).    PRINCIPLES  OF  TREATMENT.     In 

one  octavo  volume  of  625  |)agps.     Cloth,  $.'?.7."),  vet. 


One  of  the  most  useful  books  in 
which  the  practitioner  can  invest. 
It  is  a  book  worthy  of  reading  from 


cover  to  cover. —  Virginia  Medical 
Semi-Moidhhi. 


Lka  Brothers  &  Co.,  Philadelphia  and  New  York.       5 

BKYANT  (THOMAS).  THE  lMlA("riCE  OF  SURGERY.  Fourth 
American  frnin  the  foiirtli  Entcliwh  edition.  In  one  imperial  octavo  vol- 
ume of  1040  pajje-s,  with  727  illustrations.    Cloth,  $6.50  ;  leather,  $7.50. 

BIJIICHAHD  (HENRY  H.).  DENTAL  PATHOLOCIY.  New  CJml) 
edition,  tliorouuhly  revised  liy  Otto  E.  Englis,  D.D.S.  Handsome 
octavo,  iiboutGOO  pages,  with  ahout  450  illustrations,     litaihi  .fharth/. 

BURNETT  (CHARLES  H.).  THE  EAR  ;  ITS  ANATOMY,  PHYSI- 
OLOGY AND  DISEASES.  A  Practical  Treatise  for  the  Use  of 
Students  and  Practitioners.  Second  edition.  In  one  8vo.  volume  of 
580  pages,  with  107  illustrations.     Cloth,  $4;  leather,  $5. 

CARTER  (R.  BRUOENELIi)  AND  FROST  ( W.  ADAMS).  OPH- 
THALMIC SlJRtJEIlY.  In  one  pocket-size  12mo.  volume  of  559 
I)ages,  with  91  engravings  and  one  plate.  Cloth,  $2.U5.  See  Series  of 
Clinical  Manuals,  page  25. 

CASPARI   (CHARLES   JR.).     A   TREATISE   ON    PHARMACY. 

For  Students  and  Pharmacists.     Second  edition.      In  one  handsome 
octavo  volume  of  774  pages,  with  301  illustrations.     Cloth,  $4.25  tiel. 

In  a  single  comprehensive  volume  ers  instruct  from  it   with   economy 

he  presents  the  l>ody  of  information  in    time    and    etlort.     Pharmacists 

wiiit'h  to-day  constitutes  the  science  will  find  it  a  most  useful  guide  in 

and  practice  of  pharmacy  in  its  pre-  the  operations  of  their  calling  and 

sent   advanced    state.     It    is  homo-  in    the   interpretation  of  the  Phar- 

geueous,  uniform,  clear  and  aecur-  macopieia. — 'I'/ic  Smi  Fnnirisioiintt 

ale.     Students  can  learn  and  teach-  I'dcijic  DriKji/i.st. 

CHAPMAN  (HENRY  C).  A  TREATISE  ON  HUMAN  PHYSI- 
OLOGY. Second  edition.  In  one  octavo  volume  of  921  pages, 
with  595  illustrations.     Cloth,  $4.25  ;  leather,  $5.25,  net. 

In  every  respect  the  work  fulfils  |  mirable  work  of  reference  for  the 
its  promise,  whether  as  a  comjdete  physician. — Xurth  Carolina  Medical 
treatise  for  the  student  or  as  an  ad-  i  Journal. 

CHARLES  (T.  CRANSTOUN).  THE  ELEMENTS  OF  PHYSIO- 
LOGICAL AND  PATHOLOGICAL  CHEMISTRY.  Octavo,  451 
pages,  with  38  engravings  and  1  colored  plate.     Cloth,  $3.50. 

CHEYNE  (W.  W.)  AND  BURGHARD  (F.  F.).  SI  RGICAL 
TREATMENT.  In  seven  octavo  volumes,  containing  290S  pages 
with  S27  engravings,  Volume  1.,  cloth,  $3.00  net.  Volume  II.,  cloth, 
$4.00  net.  Vol.  Ill,  cloth,  $3. .")(),  iiet.  Vol.  IV.,  cloth,  .•j;3.7r.,  net. 
Vol.  v.,  cloth,  $5.0(t,  net.  Vol.  VI.,  cloth,  $5.0(1,  nel.  Vol.  VII., 
cloili,  $5.75,  nrt. 

The  hook  differs  from  all  other  after  operation,  inclmling  the  con- 
works  on  surgery  in  the  English  duet  of  the  treatment  iii  the  face 
language  by  confining  itself  .strictly  of  any  of  the  emergencies  ofsurgi- 
to  practical  considerations.  There  eal  pratice.  is  fully  set  forth.  TIk; 
is  no  theory  of  disease  or  its  eausa-  vast  material  on  which  the  authors 
tion— nothing  but  the  treatment  of  have  drawn  for  their  deductions 
patients  suHering  from  surgical  (lis-  gives  the  book  an  unusual  value, 
ease,  once  the  diagnosis  is  made.  — Molicid  Xnrs. 
The  treatment  of  patients  before  and 

CLELAND  (JOHN).  A  DIRECTORY  FOR  THE  DISSECTION  OF 
THE  HUMAN  BODY,     lu  one  12mo.  vol.  of  178  pages.    Cloth,  $1.25. 

CLINICAL  MANUALS.     See  Series  of  Clinical  Manuals,  page  25. 


6         LKA   BBUTHBR8  &  Co.,    PhILADKLPHIA   AND   NkW   YoRK. 


CLOIISTON  (THOMAS  S.).    CLINICAL  LECTITRKS  ON  MENTAL 

DISEASES.     New  (5tli)  filitioii.     In  oiu;  octavo  voliinit'  of  750  pages, 
witli  1!»  colored  phites.     Cloth,  $4. •_'">,  lift. 

COAKLF.Y  (COKNI'MilUS  G.).  THE  DIAGNOSIS  AND  THEAT- 
iMENT  OF  DISEASES  OK  THE  NOSE,  THROAT,  NASO- 
IMIAJIYNX  AND  TRACHEA.  SccomI  .'ditioii.  In  one  r.'mo. 
volume  of  55(5  jKiges,  with  U).}  ciiiLfriivings  and  4  eolorfd  plates.  Cloth, 

$12.75.  net. 

It  is  the  licst  condt'iiscd  manual  student  and  ycntTal  practitioner.  A 
that  his  reoentlv  appeared.  /In.y/nn  special  ehapter  on  therapeutics  has 
Miiliriil  iiiiil  Siiriiii-iil  Jiiiinnil.  heen  added,  which  Contains  a(!lassiti- 

Dr  ('oakley  devotes  espei'ial  at-  cation  of  drui,'9  a(,'conlin<^  to  their 
teriiion  to  the  practical  points,  such  local  action,  and  a  numlier  of  useful 
as  ex  unination,  diagnosis  and  treat-  ])rescrii)tions,  with  indications  as  to 
nieni,  thereliy  making  a  valuahle  !  their  use.  -77(<  l\<nisti!<  ('itij  Mnl- 
ac(|uisition    to    the     lilirarv    of    1\h'.  \  irall  iidrr-Ldiiril. 

COATS  (JOSEPH).  A  TREATISE  ON  PATHOLOGY.  In  one  vol* 
of  HL'9  pages,  with  ;{;{;»  engravings.     Cloth,  $5.50;  leather,  $6.50. 

COIiKMAN  (ALFRED).  A  MANUAL  OF  DENTAL  SURGERY 
AND  PATHOLO(iY.  With  Notes  and  Additions  to  adapt  it  to  Amer- 
ican Practice.  By  Tiios.  C.  STi':i.i.\v.\(iKN,  M.A.,  Ml).,  D.D.o.  In  one 
handsome  octavo  vol.  of  412  pages,  with  381  engravings.    Cloth,  $3,125. 

C'OIJilXS  (C.  F.)  aiul    DAVIS    (F.).    A    PoCKET    TEXTBOOK 

OF    MED1C.\L    DIAGNOSIS.       I'n/>nrin,i.       See  !.,„'.•<  Srri<s  ,,/ 
I'ncl.if  Text- Hiiiil.s,  i)age  IS. 

COLLINS  (H.  I).)  AND  ROCKWELL  (W.  H.).  A  POCKET 
TEXT-BOOK  OF  PHYSIOLOGY.  lUmo.  of  310  pages,  with  1.^)3 
illustrations.  Cloth,  $1.5U;  llexihle  red  leather,  $2.00,  net.  See 
Lea's  Scries  of  I'acket    Te.vt-bonks,  page  18. 

Well  written  and  up  to  date.     It  '  ])ractitioner  with   the   advances    in 


is  a  manual   admirahly  adaj)ted  to  i  tiiis    subject. — The    F/ii/siciun    and 
teach  the  beginner  the  essentials  oi'  \  Stirgeun. 
physiology,    and    to    acquaint    the  1 

CONDIE  (D.  FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  CHILDREN.  Sixth  edition,  revised  and  enlarged.  In 
one  large  8vo.  volume  of  719  pages.     Cloth,  $5.25. 

CORNIL  (V.).  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNO- 
SIS AND  TREATMENT.  Translated,  with  Notes  and  Additions,  by 
J.  Henky  C.  Simks,  M.D.  and  J.  William  White,  M.D.  In  one 
8vo.  volume  of  461  pages,  with  84  illustrations.     Cloth,  $3.75. 

CROCKETT  (M.  A.).  A  POCKET  TEXT-BOOK  OF  DISEASES 
OF  WOMEN.  In  one  handsome  12mo.  volume  of  368  pages,  with 
107  illustrations.  Cloth,  $1.50,  iitt ;  flexible  leather,  $2.00,  net. 
See  Led'ti  Series  of  I'ocket  Te.vt-bouks,  page  IS. 


This  is,  like  all  the  other  manuals 
in  this  series,  a  most  excellent  guide 
for  students  and  a  handy  reference 


book    for   j)ractitioners. — St.  Louit 
Medical  and  Surgical  Journal. 


CROOK    (JA3IES      K.)    ON     MINERAL     WATERS     OF     THE 
UNITED  STATES.     Octavo,  575  i>ages.     Cloth,  $3.50,  7(e^ 

In  such  a  book  as  this  the  medical  of  eveiy  water  of  any  known  medioi- 

profession  will  find  a  wonderful  ally ;  nal     properties. —  T/ie    Louisville 

it  is  remarkably  comj)lete  in  every  Mo)ithly  Journal. 
detail,  giving  the  results  of  analyses 


Lea    BroTHKKH  <Si   CX).,    rHlI-ADKI.PHIA    AND   New  7 

CU!iBltl<rrH   (DAVID  M.  11.).    MATERIA   MKDICA  AND  PIIAH- 
M  A( '()L()(i  Y.       Tliiiil   rilituin.      In    unc    liaiulsoine  octavo   volume 
of  !M),'i  pa^e.'',  witli  47'l  illustrations.     Cloiii,  .^4.7.'>,  net. 
A    systematic  ami  thoroiii,'li  treatise   on   tiie  entire   Materia  ^leiliea, 

animal,  vei^t'taMe  .niil  niinenil.     in  detail  ami  ai)uiulHnee  of  infornnition, 

as  well  as  richness  of  illustration,  tliis  eunveiiient  volume  lias  ni>  parallel 

on  its  siilijeet. 

CUSHXY    (AllTHril    II.).    TKXT-iJOOK   OF  I'll  A  IIM  ACOl.OGY. 

Third   edition.     Handsome   Svo.,   7.')(l    pat,'es,    with    .')_'    illustrations. 

(Moth,  $.'5.75,  net ;    leather,  s4  7.'>,  ml. 
The  l)est  exposition  of  our  knowl-    ac(|uaintini;themselves  with  the  very 
edge  of  pharnuicoloi,'y  wliieh  has  yet    latest  knowledire   on  this   very   iin- 
been  given   to    the   mediral    |»uliii<'.     portant  suhjeet.      Tlw  Mont rml  Med- 
We  can  cordially   reeoniniend   it   to    icul  JonriKil. 
all  our  reailers  who  are  desirous  of 

DAIiTONiJOHNC).    A  TRKATISK  ON   HUMAN  IMIYSIOLOtJY. 

Seventh  edition.     <  )clavo,    7-2    pages,  with    'JoJ  engravings,     (^htth, 
$5  i  leather,  $(!. 

DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.    In 

one  handsome  12mo.  volume  of  21),'5  pages.     Cloth,  .+2. 

DAVKNPORT  (F.  H.).  DISEASES  OF  WOMEN.  A  Manual  of 
Gynecology.  For  the  use  of  Students  and  Practitioneiu.  Fourth 
edition,  in  one  handsome  12mo.  volume  of  402  pages,  with  154 
illustrations.     Cloth,  $1.7.'),  )iet. 

Dr.     Davenport    has    the    ha})py    knowing,  and  presents  these  princi- 
faeulty  of  selecting  just  those  ]»oints    pies  in  a  clear,  concise  and  thorough 
in   gynecological   therapeutics    and    manner.     The  hook  can   be  highly 
surgery  which  the  student  and  junior    commendi'd. —  The  Medical  Age. 
practitioner  most  stand  in  need  of 

DAVIS  (EDWARD  P.).  A  TREATISE  ON  OBSTETRICS.  FOR 
STUDENTS  AND  PRACTITIONERS.  New  (2nd)  edition, 
thoroughly  revised.  In  one  very  luindsome  octavo  volume  of  ,S()(( 
pa(?es,  with  274  cngravii'gs  and  .'^1'  full-page  j)lates  in  colors  and  mono- 
chrome. Cloth,  $.'>.(»(),/(«/ ;  leather,  $(].()(),  //(Y.  J nsl  rraih/. 
Tlieauthor  has  fully  utilized  the  o|)portunity  presented  l»y  tht'  demand  for 

another  edition  of  his  well  known  work,  and  has  subjected  it  to  a  thorough 

revision.      It  is  a  succinct   and    clear  presentation  of  modern   ob.stetries, 

with  ample  illustration. 

DAVIS  (F.H.).  LECTURES  ON  CLINICAL  MEDICINE.  Second 
edition.     In  one  l2mo.  volume  of  2S7  pages.     Cloth,  $1.75. 

DAYTON  (HUGHFS).  AN  EPITOME  <tF  TIIE  PRACTICE  oF 
MEDK^lNI'j.     See  /.((I's  .Sr/'/V.s  nf  Mulical  F.jiitDnu a,  page 

DE  liA  BECHE'S  (GEOLOGICAL  OBSERVER.  In  one  large  octavo 
volume  of  700  pages,  with  3(J0  engravings.     Cloth,  $4. 

DE  SCHWEINITZ  (GEORGE  E.).  TIIE  TOXIC  AMBLYOPIAS. 
Their  Classification,  History,  Sym))toms,  Pathology  and  Treatment. 
Very  handsome  octavo,  240  pages,  46  engravings,  and  9  full-page 
plates  in  colors.     l)e  luxe  binding,  $4,  net. 

DRAPER  (JOHN  C).  MEDICAL  PHYSICS.  A  Text-book  for  Stu- 
dents and  Practitioners  of  Medicine.  In  one  handsome  octavo  volume 
of  734  pages,  with  .370  engravings.     Cloth,  $4. 

DRUITT  (ROBERT).     TIIE    PRINCIPLES    AND   PRACTICE  OF 

MODERN  SURGERY.     Twelfth  Edition.    Octavo,  !ttJ5  pages,  with 
373  engravings.     Cloth,  $4  ;   leather,  .^5. 


Lka  Broth liiis  &  Co.,  Philadelphia  and  New  York. 


DUANK  I  AIil<]XAM)ER).  A  DICTIONARY  OF  MKDICINK  AND 
THE  ALIilKD  SCIENCES.  Cinuprisiiig  the  Pronunciation,  Deriva- 
tion and  Full  Explanation  of  Medical,  Dental,  Pharniaecntical  and 
Veterinary  Terms.  ToLit'tiicr  with  much  Collateral  Descriptive  Mat- 
ter. Numerous  Tables,  etc.  J'ourfh  edition,  with  appendi.x.  Square 
octavo  of  tiSH  pages,  with  H  colored  plates  and  thumb  index.  Cloth, 
$;{.00,  iii't ;  limp  leather,  $4.00.  ?ir(. 

It  is  one  of  the  modern  marvels  purse.     For  the   student    iind   l)usy 

that  such  a  \ast  aggregate  of  schoi-  practitioner  it  is  decidedly  the  best 

arly  knowledge  can  be  placed  witii-  book    in     its     line. — 'J'/ic    Sdiitlirni 

in  the  command  of  a  very  modest  I'ractHioncr. 

UVDIjKY    (K.    C).      THE    PRINCIPLES    AND    PRACTICE     OF 
GYNECOLOGY.     New  (4th)edition,  thorougidy  revised.     Handsome 
octavo  of  770  i)ages,  with  420  illustrations   in  black  and  colors,  and 
K)  colored  plates.     Cloth,  $5.00,  net;  leather,  $(J. 00,  )ift ;  half  Moroc- 
co, $t).."iO,  7iet.     Just  nady. 
The  marked  success  of  this  book  is  owing  to  its  reduction  of  < 'ynecology 
to  a  rational  basis  and  its  conseciuent  simplilication  of  tlie  subject.      It 
rcijuires  a  master's  iiand  to  simplify  in  this  way,  but  once  done,  others 
can  attain  the  mastery.     Everything  in  this  work  bears  on  practice.     The 
author   has  again    revised    the   boot   thoroughly  to  date,  enriching   the 
already  notaiile  series  of  illustrations  in  black  and  colors,  with  many  new- 
engravings  and  plates,  especially  emphasizing  those  showing  the  ste|)s  of 
operations.     In  tt\is  new  edition  every  illustration  is  original. 

DUXGIilSON  (ROBIiEY).  A  DICTIONARY  OF  MEDICAL  SCI- 
ENCE. Containing  a  full  ex])lanation  of  the  various  subjects  and 
terms  of  Anatomy,  Physiology,  Medical  Chemistry,  Pharmacy,  Phar- 
macology, Therajieutics,  Medicine,  Hygiene,  Dietetics,  Pathology,  Sur- 
gery, ()phthalmology.  Otology,  Laryngology,  Dermatology,  Gynecol- 
ogy, Obstetrics,  Pediatrics,  Afedical  Jurisprudence,  Dentistry,  etc.,  etc. 
By  ROBLKY  DUNGLISON,  M.  D.,  LL.  D.,  late  Professor  of  Institutes 
of  Medicine  in  the  Jetlerson  Medical  College  of  Philadelphia.  New 
(28d)  edition,  thoroughly  revised  by  THOMAS  L.  Stkdman,  M.D., 
in  one  magnificent  imperial  octavo  volume  of  12'J0  pages  with  577 
illustrations,  including  84  full  page  plates  mostly  in  colors.  With 
thumb  letter  index.  Cloth,  $8,  net;  leather,  ••^H,  net;  half  Morocco, 
8(t..50,  net. 
The   name  of   Dunf/lison    stands 

forth  as  that  of  the  greatest  medical 

lexicographei     of     the    English 

language.     For  seventy-five    years 

this   work   has   been   the    standard 

dictionary    used    by    the    English- 
speaking   medical  world,  and   now 

in    its   twenty-third  edition   it   is  a 

pleasure  to  realize  that  it  remains 

fully  uj)  to  the  standard  of  the  mo*-t 

modern    nHpurements.  —  Antcricnn 

Jounidl  oj  the  Medical  Sciences. 

I)i,n(/lis(>ii\'<  Medical  Dictionary 
remains  what  it  has  always  been, 
the  criterion  of  medical  lexico- 
graphy.— Medical  Jierieir  of  Re- 
rieirs. 


The  standanl  work  of  its  kind. — 

American  Pracfitio7ier  and  News. 

Along     with     Gray'n     Anatomy, 

Dinujlinan's   Dictinnarj/    has    stood 

the  test  of  time  and  practical  value. 

I  It    stands    at    the    head.— rZ/^/m/ 

Jierieir. 

It  has  held  the  first  place.  Others 
have  appeared  and  vanished.  Dtnuj- 
li.son  became  an  institution  in 
medicine.  It  is  a  thorough  ex- 
emplar of  twentieth  century  medi- 
cine. Complete,  thorough,  clear. 
Pre-eminent  among  medical  dictiou- 
ari(!s. — St.  Louin  Medical  and  Siir- 
(jicul  Journal. 


DUNHAM  (EDWARD    K.).      :M0RBID    AND     NORMAL     HIS- 
TOLOGY.    Octavo,  4r)0  pages.with  3«3  illustrations.  Cloth,  $3.25,  net. 

The  best  one-volume  text  or  refer- 1  of  published  in  America. —  Virginia 
euce  book  on  histology  that  we  know  I  Medical  iSet)ii-Jfuut/iti/. 


Lea  Brothkhs  &  Ck).,  Phii-adrt.phia  and  New  Yokk.       9 


DUNHAM  (EDWARD  K.)  NOHMAL  II[STr)F.O(J Y.  New  (Mrdt  an<l 
revised  edition.  Octavo,  'V,U  piifres,  vith  i'(iO  illiistriitions,  ('lotli, 
.*i2.7t5,  net.     JiiM  mulif.     A    Holier  <>/  tli,-  i»-irit>iis  itlitian  is  nppniilrd. 


Thisisa  splendid  work,  clear  and 
succinct,  but  at  the  same  time  ex- 
haustive  enouiih    to    meet   the    de- 


man<ls()f'theday.     Theillnstrntions 
are  up-to-date  in  every  particular. — 

A  iHiriciiii    I'riiftilitiiiir  and  .\rirn. 


DWIGHT  (EDWIN    WELliES).      .\N    KIMTOMK    OF   MKDIC.M, 

.H'RISFMllTDKNCE.     12mo,   210   pajres.     ("loth.   $1  iirl.     See  /,r„',s 
Scn'tN  i>f  Mriliciil    h' iiilmms,   pajj'"    l*^. 

-AN  EPITOME  OF  TOXirOUx;  V.     See  L,„'s  S,ri,s  .,]  Mnlinil 

/■Jjiiliinics,  |)atce  IS. 

ECKLEY  (WIIililAM  T.).  A  GUI  OF  TO  OISSFCTION  OF  THE 
HU.MAX  BODY.  Octavo,  400  pa^'cs,  220  illustrations  in  black  and 
colors.     (Moth,  *,3.r)0  7irt. 

An  exceediiif^ly  useful  hand-book  an<l  the  text  i>lain  and  concise.     We 

for  the  student,  prepared  to  be  used  rei,'ard  it  as  a  most  excellent  book, 

in  connection  with  the  most  popular  Xashrillr  .lonnial  of  Medicine  ami 

text-books  of   the    day,   (irai/   and  Siirgrrj/. 
Grrrish.    The  arrant,'ement  is  good 

ECKLEY  (WII.LIAM  T.).  REGIONAL  ANATOMY  OF  THE 
HEAD  AND  NECK.  Octavo,  240  pa<,'es,  with  ;<6  engravin'TH  and 
20  plates  in  black  and  colors.     Cloth,  ^2.50,  net. 

A  most  excellent  work  of  especial  that  chai)ter.     The  engravings,  and 

interest  to  the  dentist.     It  is  seldom  especially    the    colored    plates,   are 

one  sees  a  book  .so  well  arranged  and  fine  and   if  the  student  cannot  (jet  a 

so  concisely  written  as  this  one.     At  correct    understanding    from     their 

the  end  of  each  chapter  (juiz  (pies-  study  it  must  certainly  be  his  own 

tiona  are  given  covering  the  text  in  fault. — The  Deidal  Suniniari/. 

EDES  (ROBERT  T.).  TEXT-BOOK  OF  THERAPEUTICS  AND 
MATERIA  MEDI(;A.  In  one  8vo.  volume  of  544  pages.  Cloth,  $3.50. 

EDIS  (ARTHUR  W.).  DISEASES  OF  WOMEN.  A  Manual  for 
Students  and  Practitioners.  In  one  handsome  8vo.  volume  of  576  pages, 
with  148  engravings.     Cloth,  $.S. 

EGBERT  (SENECA).  A  MANUAL  OF  HYGIENE  AND  SANI- 
TATION. New  (.'5rd)  and  revised  edition.  In  one  12mo.  volume 
of  467  pages,  with  86    illustrations.     Cloth,  $2.25,  net. 

A  concise,  comprehensive  manual,  lay  reader.  It  deals  with  personal 
alike  suitable  for  the  medical  stu-  hygiene  as  well  as  public  health. — 
dent,  sanitary  inspector  and  for  the    The  Siiiiitdrian. 

ElililS  (GEORGE  VINER).  DEMONSTRATIONS  IN  ANATOMY. 
Eighth  edition.  Octavo,  716  pages,  with  249  engravings.  Cloth, 
$4.25 ;  leather,  $5.25. 

EMMET  (THOMAS  ADDIS).  THE  PRINCIPLES  AND  PRAC- 
TICE OF  GYNAECOLOGY.  Third  edition.  Octavo,  880  pages,  with 
150  original  engravings.     Cloth,  $5 ;  leather,  $6. 

ERICHSEN  (JOHN  E.).  THE  SCIENCE  AND  ART  OF  SUR- 
GERY. Eighth  edition.  In  two  large  octAvo  volumes  containing 
2316  pages,  with  984  engravings.     Cloth,  $9  ;  leather,  $11. 

ESSTG(CHARI.ES  J,),  PROSTHETIC  DENTISTRY,  Sec  American 
Text-Booh  of  Dentistry,  page  2. 

ES9IG  (CHARLES. I.)  aii<l  KOENIG   (Al  (ilSTUS).     DENTAL 

METALI-UIUJY.      New  (5tli|  edition,  thoroughly    revised,      12mo, 
318  pages,  76  engravings.     Clolh,  >2.0o, /mV.    .///s/    rKuh/. 


10     Lea  Brothkrs  &  Co.,  Philadki.phia  and  Nkw  York. 


EVANS  (DAVID. I.).    A  I'OCK  KT  TEXT-HOOK  OF  OIJSTKTIlirS. 

in  one  handsorne  I'imo.  volmiic  of  4()!t  paj^'es,  with  \4H  illustrations. 

Cloth,  .^l.rr.,    iirf ;    limp    IciithtT,  $_'.'2r),   mf.    Lra'n   Strict  oj   IWkrt 

Ti\rl-h(i()lcx,  edited  hv  I5KKN  !?.  (lAl.l.AlDl'.r,  M.D.   Sec  pn«e  is. 

\\'rittcn   foi'  the   iiicdictal  sliidi'iit  i  It  isciiinpcndioiis,  (Miricise  and  readi- 

and    praplitioncr  l)y  one  whose  e\- i  ly  intelliyihle,  giving;  the  essentials 

erience,  l)(»th  <!linienl  and  teaching,  :  of  its   siiiiject    in    its   most   modern 


I 


lan  speeialiy  fitted  him  for  the  task.  '  aspect.— ///*///>/(«   Mnliad  Journtil, 

EWINC.  (JAMES).  CI.INICAI,  PATFIOLOdY  OF  TliK  ISLOOD.  A 
Treatise  on  the  (ieneral  Principles  and  Special  Appli<'ations  of 
Fteinatolouy.  New  (2d)  edition,  thorou!,dily  rcivised.  Handsome 
octavo,  4!i2  pafi;es,  l.'{  en;,'ravin;;s,  18  colored  jdates.     (Moth,  $.'{.r)0,  )ii(.. 

In  all  of  those  medical  colleges  in  certainly  made  it  a   reliable  giiide 

which  heniatoloyy  is  taufjht  the  hook  for  all  those  who  desire  to  enter  up- 

hefore  US  has  been  recommended  for  on  tiie  work  of  blood  examination, 

a  text-book,  and  no  lietter  one  cotild  — St    Loiiix   Midlcal   itnd  Siiniinil 

have  been  chosen.     The  author  has  JminKil. 

EXAMINATION  SERIES  (STATE  BOARD).  See  page  2(5. 

PARQUHARSON  (ROBERT).  A  (^UIDE  TO  THERAPEUTICS. 
Fourth  American  from  fourth  English  edition,  revised  by  Frank 
WooniUTRY,  M.  D.     In  one  12nio.  volume  of  581  pages.    Cloth,  $2.50. 

PER(iUSON  (J.  B ).     AN  EPITOME    OE    NOSE    AND   THROAT 

DISEASES.     See  L,a\s  Srrirx  of  Mrdiail  Epitomes,  page  18. 

FIELD  (GEORGE  P.).  A  ]\IANUAL  OF  DISEASES  OF  THE 
EAR.  Fourth  edition.  In  one  octavo  volume  of  391  pages,  with  73 
engravings  and  21  colored  plates.      Cloth,  $3.75. 

FINDLEY   (PALMER  D.).      A  TREATISE  ON   GYNECOLOGI- 
CAL  DIA<;N0SIS.     Octavo,  4!t;{  pages,  210  engravings,   15   plates, 
in  Idack  and  colors.     Cloth,  .$1.50;  leather,  !^5.r)(i,  net. 
This  elaborate  work  will  occupy    and   will   be   found   of  the  greatest 
a    uni(|ue    place    in    gynecological    value  to  both.  It  is  thoroughly  illus- 
literature  inasmuch  as  it  is  the  lirst    trated     with    excellent     cuts     and 
on     the    subject     in     the     English    colored  engravings.     The  text  is  full 
language.     It  is  adapted  to  the  needs    and   j)lain — Xoshrille    Journal    of 
of   both   student  and    practitioner.    Medicine  and  Simierii. 

FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE.  Seventh  edition,  thoroughly  revised 
by  Frkdrrick  P.  Henry,  M.D.  In  one  large  8vo.  volume  of  1143 
pages,  with  engravings.     Cloth,  $5.00  ;  leather,  $fi.OO. 

FLINT  (AUSTIN).  A  PRACTICAL  TREATISE  ON  THE  DIAG- 
NOSIS AND  TREATMENT  OF  DISEASES  OF  THE   HEART. 

Second  edition  enlarged.    In  one  octavo  volume  of  .550  pages.    Cloth,  $4. 

ON  PHTHISIS:  ITS  MORBID  ANATOMY,  ETIOLOGY,  ETC. 

A  Series  of  Clinical  Lectures.      8vo.  442  pages.     Cloth,  $3.50. 

-ESSAYS  ON  CONSERVATIVE  MEDICINE  AND  KINDRED 


TOPICS.     12mo,  214  pages.     Cloth,  81.38. 
FORl^IUIiARY,  POCKET.  See  page  32. 

FOSTER  (MICHAEL).    A  TEXT-BOOK  OF  PHYSIOLOGY.    Sixth 

and  revised  American  from  the  sixth  English  edition.     In  one  large 

octavo  volume  of  !>23  pp.,  with  257  illus.     Cloth,  $4.50;  leather,  .$5.50. 

Unquestionably  the  best  book  that  !  busy  physician   it  can    scarcely   be 

can  be  placed  in  the  student's  hands,  i  excelled. —  ThePhila.  Polyclinic. 

and  as  a  work  of  reference  for  the  i 


Lka  Brothkea  a  Co.,  Phii.adei.imiia  and  Nrw  York.      11 

FOTHERGIIili  (J.  MILNER).  THE  PRACTITIONKR'S  IIAND- 
nOOK  OF  TIIKATMKNT.  Tliiid  cditiDn.  In  one  handsome  octavo 
volume  of  6M  pa^es.     Cloth,  J."?.?') ;  leather,  $4.75. 

FOWNES  (GEORGE).  A  MANUAL  OF  KLFMFNTARY  CHKM- 
ISTRY  (INOI{(wVNI(;  AND  OIKJANK").  Twelfth  edition.  F,m- 
iMxiyin^,'  Watts'  I'hysical  and  Inorganic  ChrmiHry.  I'Jmo.,  1061 
pa^e.s,  168  enKravint;s,  and  1  eolored  plate.    Cloth,  lf2.7.'') ;  leather,  $.'{.25. 

FRANKIiANl)  (E.)  AND  JAPP  (F.  R.).  INOIKUNK^  CHEMISTRY. 
Ill  one  handsome  octavo  volume  of  677  pa^'es,  with  51  enj,'ravinf;s  and 
2  plates.     Cloth,  $.'?.7r) ;  heather,  $4.7.".. 

FUIiliER  (EUGENE).  DlSOllDEUS  OF  THE  SEXUAL  OR- 
QANS  IN  THE  MALE.  la  one  very  handsome  octavo  volume  of 
2,'<8   pa^e-s,  with    25   enj;ravinj,'S  and  8  ftill-page  i)lftt«'fl.      Cloth,  $2. 

GAIil.AUDET  (RERN  R.).  A  I'OCKET  TEXT-HOOK  ON  SUR- 
GIORY.  In  OIK' handsome  TJmo.  volume  of  about  400  pajjes,  with  many 
illustrations.    S/ior/li/.     See  Lfii's  Srrirs  of  /'ockrl  Te.vt-l>i>ok)<,  page  18. 

GANT( FREDERICK  JAMES).  THE  STUDENT'S  SURGERY.  A 
Multum  in  Parvo.  In  one  aiiuare  oetavo  volume  of  845  pages,  with 
159  engravings.     Cloth,  $.'5.75. 

GAYIiORI)  (HARVEY  R.)aiul  ASCHOFF  (lilTJ)WIG).     THE 

PRINCIPLES  OF  PATHOLOGICAL  HISTOLOGY.     With  an  in- 
troductory note  by  William  H.  Wki.ch,  M.  D.     Quarto,  364  pages, 
with  81  engravings  and  40  full-page  pliites.     Cloth,  >;7.50,  7iet. 
Admirably  arranged  and   beauti-    tion  of  a  work  which  should  be  in 
fully  illustrated.     The   authors  are    the  hands  of  every  student  of  morbid 
to  be  eongratulatefl  on  tlie  produc-    histology. — London  Practitioner. 

GERRISH  (FREDERIC  H.).     A    TEXT- BOOK   OF   ANATOMY. 

By  American  Authors.  Edited  by  Frederic  H.  Gerrish,  M.  D.    Second 

and  revised  edition.     In  one  imperial   octavo  volume  of  i».S7  pages, 

with  lOO.'i  illustrations  in  black  and  colors.    Cloth,  $().50,  ;((/.  leather, 

$7.50,  net;    half  Morocco,  .*8. 00, //r/. 

The   illustrations  far  outnumber       The  text  is  accurate,  concise,  and 

find  exceed  in  size  and  in  profusion    gives   the    e.s.sentials   of  descriptive 

of  colors  tliose  in  any  previous  work  ;    anatomy  with  less  waste  of  words  and 

and  they  can   well  claim  to  be  the    better  emphasis  of  important  points 

most  successful  series  of  anatotnical    than   any    similar    text-book    with 

pictures  in  the  world. — The  Amrri-    which  we  are  familiar. —  The  Boaton 

can  Practitioner  and  News.  Mrdinil  ntid  Snrriicit/  JourxnI. 

GIBBES  (HENEAGE).  PRACTICAL  PATHOLOGY  AND  MORBID 
HISTOLOGY.   Octavo,  314  pages,  with  60  illustrations.    Cloth,  $2.75. 

GRAY    (HEXRY).      ANATOMY,   DESCRIPTIVE    AND    SURGI- 
CAL.    New  (fift<'enth)  edition  thorouLdily   rcvi.sed.     In  one  im|)erial 
octavo   volume  of   lL'4!)  j)ages,  with   780  large  and  elaborate  engrav- 
ings.    Price  with  illustrations  in  colors,  cloth,  .$6.2.">,  «<f/ /  leather, 
•*7.25,    net.      Price,    with    illustrations    in    black,    cloth,   $5.50,   net; 
Ieatlier,$6.50,  net. 
This   is    the  best  single   vohime    so  indefinitely.     No  book  will  ever 
upon    Anatomy     in     the     p]nglish    take  its  place  liefore  the  Examining 
language.— Universiti/  Medical  Mug-    Boards  of  this  country — it  will   be 
mine.  their     standard. —  'I'lu        Aincriroii 

Holds  first  place  in  the  esteem  of    Pntrtlliinicr  otid  Xiirs. 
both    teachers    and    students. —  The       The  most  largely  used  anatomical 
Brooklyn  Medical  Journal.  text-book  published  in  the  English 

Without  a  doubt  the  most    com-    language.— ^ /*»«/«  of  Surgery. 
plele   work    on  anatomy   jjublisbed        ^;r«»/''''.^""'""V/aftords  the  student 
in  the  English  language.     (/»//// still    more    satisfaction    than    any  other 
renmiiis  i/it  text-book  of  all  medical    treatise  with  which  we  are  familiar, 
students,  and  will  <loubtlevSs  remain  ,  — Buffalo  Med.  Journal. 


12      Lea  Brothkrs  &  Co.,  Phii-adri-phia  and  New  Yoek. 


<;ravho\  (('HAiifiFis  p.).     I)|sp:ases  of  thk  tiikoat, 

NnSK,  AND    ASS()(MATKI)   AFriXTIONS  OF   THK    FAR.     In 

Olio  IiiukIhiiiiic  oetiivn  voluiiic  of  "(48  iiHirts   witli   121'  engravings  and 
iS  plak'H  in  colors  and  monochioini'.     Clotli,  '^'A.M,  net. 

Tl    i«    a    {(raclical   l>onk,   tolliip,'  and   it   is  proportionately  valiialde. 

"  not  only  what  to  do,  luit  liow  to  do  Thr  hook    is  vveil  written  Miid   is  a 

il."  Under  "Treatment,"  Itie  author  serviceahle  and  praotieal  addition  to 

is  very  evidently  pnd  sincerely  yiv-  the  literature  of  the  siilijectH  treated, 

ing,    not    compilations    from    other  —Mnlical  liccitrd. 
men's  work,  i)iit  hisown  experiences, 

ORFKN  (T.  HENRY).    PATIIOLO(JY   AND  MORIUD  ANATOMY, 

Ninth  edition.     In  one  handsome  octavo  volume  of  'ul  paijes,  with 
3.S!t  engravings  and  4  colored  plates.     Cloth,  %'^.'l^>,  nrf. 

The  work  is  an  essential   to   the    date  text-hooks. —  Virginia  Medical 
practitioner — whether  as  surjjeon  or    Monthly. 
physician.     It  is  the  hest  of  iip-to-  , 

GREENE  (WILIilAM  H.).  A  MANUAL  OF  MEDICAL  CHEM- 
ISTRY. For  the  Use  of  Students.  Based  upon  Howman's  Medical 
Chemistry.     In  one  12mo.  vol.  of  310  pages,  with  74  illus.   Cloth,  $1.75. 

CiRINDON  (JOSEPH).  A  POCKET  TEXT-HOOK  OF  SKIN 
DISEASES.  In  one  handsome  12mo.  volume  of  ;5tJ7  pages,  with  39 
illiLStraiions,  Cloth,  .-?L'.(»0,  urt ;  flexihle  leather,  $'2,.")(),  net.  See 
Lea\9  Serie.'i  of  Pockrl  Text-hooks,  page  18. 

A  compentlious  and    tru.stworthy  tologv.    Asa  thera|)eiitic  adviser  for 

guide  hook    for  the  practitioner  as  the  doctor  it  is  replete  with  direc- 

wpII    as    student,    emhodying    the  tions  and   valualde   formuhe. — 'I'ltr. 

most  recent  developments  in  derma-  Virqinia  Medical  Scnii-Monthli/. 

GROSS  (SAMUEL.  I).).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES, INJURIES  AND  MALFORM.\TIONS  OF  THE  URINARY 
BLADDER,  THE  PROSTATE  GLAND  AND  THE  URETHRA, 
Third  edition.    Octavo,  574  pages,  with  170  illustrations    Cloth,  $4.50. 

GUE\THER(A.E.  ANI>T.  C).    AN  EPITOME  OF  PHYSIOLOGY. 

12mo,  22.")  l)age8,  illustrated.    Cloth,  $1,00,  vet.     Lca'ti  Series  of  Medi- 
cal Epitomes.     See  l>age  IS. 

HABERSHON(S.  O.).  DISEASES  OF  THE  AI'.DOMEN.  Second 
American  from  the  third  English  edition.  Octavo,  554  pages,  with 
11  engravings.     Cloth,  .•^3.50. 

HALE  (HENRY  E.).  AN  EPITOME  OF  ANATOMY.  12mo., 
3H!t  pages,  71  engravings.  Cloth,  -SI. 00,  net.  Sev  Lea's  Srricft  of 
Medical  Kpitonits,  pau'e  18. 

HAIili  (WINFIELl)  S,).  TEXT-BOOK  OF  PHYSIOLOGY.  Octavo 
of  672  pages,  with  343  engravings,  and  6  full  page  colored  plates. 
Cloth,  $4.00,  net  ;   leather,  $5.00,  net. 

Students  and  teachers  may  j)ur- j  The  clearness  with  which 
chase  the  work  with  the  certainty  ;  physiological  facts  are  tlemonstrated 
that  they  will  olitaiii  a  thorouehly  makes  il  of  special  value  to  the 
sound  and  reliahle  exposition  of  the  ,  medical  student.  Western  Medical 
present  state  of  physiological  know-  i  Review. 
ledge. — 'iiic  London  Lanccl,  I 


Lea  Bkotmkuh  &  Co.,  Puri.ADKi.PniA  and  New  York.      13 


HAMII/rON  (AliliAN  MCliANI-:).  NKIIVOIKS  DISKASKS,  THKIH 
DKSCUn'TION  .VNI)  TIlK.VTM  KNT.  Stcoiid  and  reviHed  edition. 
In  one  octavo  volume  of  5i»8  pag»!S,  with  72  engravings.     Cloth,  $4. 

HAMILTON  I  Ml  LDllKD).     A  POCK  KT  TEXT- MOO  K    OF   MAS- 

8A(iK.     I 're  paring.     Hi'ti  /.ki's  Sm'rfi  of  I'nckrl  'I'l  .rl-Hi>i)l,:-<,  page  Is. 

HARDAWAY  (W.  A.).  MANUAL  OF  SKIN  DISKASKS.  Second 
edition.  In  one  llinio.  volutne  of  ')ti(l  pages,  with  40  iihistnitions  and 
2  plates.     Cloth,  $L'.2:),  »>■(. 


Till'  l>est  of  all  the  small  liooks  to 
rec<tmmen(l  to  stmlents  and   practi 
tioners.     I'rohably    no   one    of    our 
dermatologists  has  had  a  wider  every- 

HAIll^J  (HOBAllT  AMOKY). 

USK  OF  SYMPTOMS  IN  THK 

edition.  In  one  octavo  •  ohimc 
and  2.')  full-page  colored  plates 
net;    half  .Morocco,  $6. nO,  jic/. 

Dr.  Hare  is  eminently  i>ractical, 
he  appreciates  the  needs  or  the  gen- 
eral practitioner ;  and  in  presenting 
the  symptoms  as  met  at  the  hedside 
and  discussing  disease  as  it  actually 
appears,  he  has  no  peer.  The  new 
etlition  has  heen  carefully  revised, 
and  its  scope  has  iiecn  widened  to  in- 
clude not  only  symptoms  but  also 

HARE  (HOBART  AMORY).  A  TEXT-BOOK  OF  PRACTICAL 
THERAPEUTICS,  with  Special  Reference  to  the  Application  of  Reme- 
dial Measures  to  Disease  and  their  Employment  upon  a  Rational 
Basis.  With  articles  on  various  subjects  by  well-known  specialists. 
Ninth  and  revised  edition.  In  one  octavo  volume  of  851  pages, 
with  1(»5  engravings  and  4  colored  plates.  Cloth,  $4.00,  h^<;  leather, 
$5.00,  net;  half  Morocco,  $r).50,  nrt. 
.lust  the  book  the  active  physician  for  administration  are  given.  A 
most  needs.  He  generally  needs  com{)lete  index  of  diseases  and 
the   information  he   seeks  quickly,    remedies  makes  it  an  easy  reference 


day  elinical  experience.  His  great 
strength  is  in  diagnosis, deMCi'i]>tions 
of  lesions  and  especially  in  treat- 
ment.— Jitdinna  Medicnl  Journal, 

PRACTICAL    DIAGNOSIS.     THE 
DIAGNOSIS  OF  DISEASE.     Fifth 

of  (J!I2  pages,  with  240   engravings 
.     Cloth,  $.■■).( )0, /(^« ;    leather,  $(1.00, 

physiea!  signs  and  clinical  tests. 
Thi«  makes  the  treatise  a  complete 
guide  for  the  purposes  of  diagnosis. 
The  chemical  and  microscopical  ex- 
amination of  the  t)lood  is  described 
in  detail.  Directions  as  to  urinary 
diagnosis  are  concise  and  complete. 
— Nf.   Louis  ('i)uriir  iij  Malicinv. 


too,  and  here  he  finds  it,  accessible 
clear  and  adeiiuate.  On  every 
occasion  we  have  ct)nsulted  its  i)ages, 
and  tney  are  many,  we  have  never 
turned  away  in  disappointment. 
This  must  continue  to  be  the  text- 
book, par  excellence,  of  therapeutics. 
—  Hnfjalo   Mcdicid  Jonrnrd. 

We  know  of  no  book  which  is  its 
eciual    in    practical   therapeutics. — 
Hoxton  Mcdicid  and  Siiniicid  d mir 
ntd. 

The  great  value  of  the   work   lies 


work.  It  has  been  arranged  so  that 
it  can  be  readily  used  in  connection 
with  Hare's  Practical  Diagnosis. 
For  the  needs  of  the  student  and 
general  practitioner  it  has  no  equal. 
— Medical  Sentinel. 

The  best  planned  therapeutic  work 
of  the  century. — American  Prac- 
titioner and  News. 

It  is  a  book  precisely  adapted  to 
the  needs  of  the  busy  practitioner, 
who  can  rely  upon  finaing  exactly 
what  he  needs.— TAe  National  Med- 


in  the  fact  that  precise  indications    ical  Review. 

HARE  (HOBART  AMORY)  ON  THE  MEDICAL  COMPLICA- 
TIONS AND  SEQUEL.E  OF  TYPHOID  FEVER.  Octavo,  276 
pages,  21  engravings  and  two  full-page  plates.     Cloth,  $2.40,  net. 

A  very  valuable  production.   One    read  with   great  profit. — Cleveland 
of  the   very   best    products  of    Dr.    Journal  of  Medicine, 
Hare  and  one  that  every  man  cau 


14     Lka  Brothrbs  &  Co.,  Philadri-phia  and  Nkw  York. 

HARE'S  SYSTKM  oK  l'U.\(TICAI.  TH  KllAlMCUTICS.  Inn  seru-s 
of  ooiitribiitioiiH  by  <>tiiiiieiit  itractitionerH.  >Si'(;(iii(l  edition.  In  three 
lar^'e  octavo  volnnu'H  oontuininj,'  LT)!*.'!  pn^es,  with  457  enyravinKS 
ami  2(5  full-pa,i,'«!  plates.  I'rioc  per  volume,  cloth,  .'f.'i.OO ;  leatlier, 
$<!.(tO;  half  morocco,  .^7.00.  I'uli  prospec^tus  free  on  applicatiuu. 
For  sdlr  by  suhKiription  only. 

The  System  is  one  of  tlif  most  ini  wori<,    one     tiuit    tlie     well-known 

l)ortan'  additions  a   busy   piiysiisian  editor  constantly   presents,    is    tlie 

can   make  to  tin  working  iil«ratur(!  everyday     \vorl\ai)iiity      of    treat- 

of    his     library. —  liiifjalu     Mnllnil  inents     advoeated.      Here     are     no 

./niiniiil.  ltnj,'thy      tlieoretical      dissertations 

The  volumes  are  |)raetical.     They  lar^'ely  pa<l(U'd  by  (piotations  from 

rclleet  the  editor's    appreciation    of  Enro|)ean  autiiors,  but  eoncise,  prac- 

modern    medicine.     The    third   vol-  tical    ruits  that  can  be  made  to  tit 

ume  is  ffiven  up  to  surf,'ery  and  the  presmt-day   needs.      WllAT,     WHY 

specialties,  and  this  makes  the   set  and  now  are  tiie  (piestions  with  ref- 

suital)lefor  tiie  general  practitioner,  erenee  to  tiif  use  of  drut,'8  that  the 

— 'I'hc  /id.ftoii  M ((//(-(il  (ind  Siiri/icdl  imthorn    answer  —  jtartieularly    the 

Journal.  IloW. — Mrdicul  Neira. 

The    dominant    feature    of    the 

HARRINGTON  fCHARIiKS).  PRACTICAL  HYCIIENE.  Second 
edition.  Handsome  octavo,  75."»  pages,  11,'}  engravings,  12  jtlates. 
Net,  .$4.25. 

This  book  is  by  far  the  best  work-  at  the  same  time  is  perfectly  familiar 
ing  manual  of  practical  hygiene  that  with  allied  itranches,  which  are  so 
has  yet  appeared  in  the  English  necessary  for  a  full  comj)relienBion 
language.  The  subject  is  handleil  of  the  broad  subject  treated.  It  ia 
exceedingly  well,  and  shows  that  its  thoroughly  uj)  to  date. — interatitte 
author  is  a  practical  iiygienist,  and  ;  Medical  Journal. 

HARTSHORNE  (HENRY).  A  CONSPECTUS  OF  THE  MEDI- 
CAL SCIENCES.  Comprising  Manuals  of  Anatomy,  Physiology, 
Chemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and  Ob- 
stetrics. Second  edition.  In  one  royal  12mo.  vol.  of  1028  pages,  with 
477  illus.    Cloth,  $4.25 ;  leather,  $5. 

HAYDEN  (JAMES  R.).  A  POCKET  TEXT-BOOK  OF  VENER- 
EAL DISEASES.  Third  edition.  In  one  12mo.  volume  of  304 
pages,  with  66  engravings.  Cloth,  $1.75,  net.  Flexible  leather, 
$2.2."),  fiel.     See  Lea's  Series  of  Pocket  Te.tt-Books,  page  18. 

The  volume  is  practical,  concise,    it  is  particularly  thorough. — l^icific 
definite  and  satisfactorily  full.     In    Medical  Journal. 
matters  of  diagnosis  and  treatment 

HAYEM  (GEORGES)  AND  HARE  (H.  A.).  PHYSICAL  AND 
NATURAL  THERAPEUTICS.  The  Remedial  Uae  of  Heat,  Elec- 
tricity, Modifications  of  Atmospheric  Pressure,  Climates  and  Mineral 
Waters.  Edited  by  Prof.  H.  A.  Hark,  M.D.  In  one  octavo  volume 
of  414  pages.with  113  engravings.    Cloth,  $3. 

HERMAN  (G.  ERNEST).  FIRST  LINES  IN  MIDWIFERY.  In 
one  12mo.  vol.  of  198  pages,  with  80  engravings.  Cloth,  $1.25.  See 
Student' 3  Series  of  Manuals,  page  27. 

HERMANN  (Ij.).  EXPERIMENTAL  PHARMACOLOGY.  A  Hand- 
book of  the  Methods  for  Determining  the  Physiological  Actions  of 
Drugs.  Translated  by  Robert  Meade  Smith,  M.  D.  In  one  12mo. 
Tolume  ot  199  pages,  with  32  engravings.     Cloth,  $1.50. 


L.KA    BkUTHUIW  &  CU.,    PUILADKLFHI A   AND  NEW   YoBK,       16 


III<1RKICK  (JAMKS  «.)•  A  HANDBOOK  OF  DIAGNOSIS.  In 
one  hanuHonie  l^mo.  voliuno  of  4'J!)  pugcH,  with  80  engmvingH  and  2 
colored  plates.     Cloth,  $'J.50. 

We  oonimeiid  the  hook  not  only  to  Execlh'ntly    arranged,    practical, 

the  nndergraduatf,  hut  also  to  the  conciHe,    up-to-date,   and  eiiiini'ully 

physician  who dt'Birt's a  ready  means  well  fitte<l  for  the    use  of  the  prac- 

of  rrfreshing  his  knowledge  of  diai;-  titioner  an  well   a-softhc  student.-- 

nosisin  thtM'\igencieHof  prot'fssiomil  Chicago  Med.  liecorder. 
life. — Memphia  Medical  Moulhhj. 

HERTFJl    (C.    A.).      LECTURKS  ON  CHEMICAL  I'ATIIOLOOY. 
Ln  one  I'Jmo.,  volume  of  !.">  1  pages.     Cloth,  $1  7r>,  ml. 

The  lectures  are  eminently  prac-  hody,  hut  rather  an  ae<;()unt  of  the 

tioal.     A    great   variety  of   suhjects  altered  chemical  changes  which  take 

is   dealt  with  i>'.   a  most   attractive  place  in  the  ditl'ereiit  organs  and  se- 

nninner.     Thtt  volume  is  not  a  de-  cretions   in    various    di.seases.     The 

Ncriptionofthe  notnnil  |)hysiologi<'al  hook  is  full  of  interesting,  practical 

processes  going   on   in  the  iiealthy  points. --./o/jyix  llojikiiis  linlhliu. 

Hllili  (BERKELEY).  SYPHILIS  AND  LOCAL  CONTAGIOUS 
DISORDERS.    In  one  8vo.  volume  of  47y  pages.     Cloth,  $3.25. 

HIIililER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES. 
Second  edition.  In  one  royal  12mo.  volume  of  353  pages,  with  two 
plates.    Cloth,  $2.25. 

HIRST  (BARTON  C.)  AND  PIERSOL.  (GEORGE  A.).  IIU^iAN 
MONSTROSITIES.  Magnificent  fidio,  containing  220  pages  of  text 
and  illustrated  with  12.S  engravings  and  .'W  large  photographic  plates 
from  nature.   In  four  parts,  price  each,  $5. 

HOBLiYN  (RICHARD  D.).    A    DICTIONARY   OF  THE  TERMS 

USED  IN  MEDICINE  AND  THE  COLLATERAL  SCIENCES. 
Thirteenth  edition.  In  one  r2mo  volume  of  845  pages.  Cloth, 
$3.00,  lift. 

This  is  a  volume  of   almost    Poo    that  it  has  gone  through  12  editions 
pages,  printed  in   easily-read    type,    is  an  evidence  that  the  medical  pro- 


and  is  fully  up  to  date,  enihracin!,^  |  fessiou    has    found    it    meets    their 
practically  all  the  terms.     The  fact    wants. — Cantida  MnlinU  litcord. 

HOLIilS  (A.W.).  AN  EPITOME  OF  MEDICAL  DIAdNOSIS.  See 
Lvn's  SvricK  oj  Medical  !•'. pitinnis,  Pi'g'-'  l''^- 

HOLiMES  (TIMOTHY).  A  TREATiSE  ON  SURGERY.  Its  Prin- 
ciples and  Practice.  Fifth  edition.  Edited  by  T.  Pickering  Pick, 
F.R.C.S.  In  one  handsome  octavo  volume  of  1008  pages,  with  428  en- 
gravmgs.    Cloth,  $6.00 ;  leather,  $7.(iO. 

HOLMES  (TIMOTHY).  A  SYSTEM  OF  SURGERY.  With  notes  and 
additions  by  various  American  authors.  Edited  by  John  H.  Packard, 
M.D.  In  three  8vo.  volumes  containing  3137  pages,  with  979 engravings 
and  13  plates.    Per  volume,  cloth,  $6.0(J ;  leather,  $7.00. 


16     Lea  BROTHKua  &  Co.,  Philadelphia  and  New  York. 


HUNTINGTON  (GKORGK  S.).  A  TREATISE  ON  ABDOMINAL 
ANATOMY.  Quarto,  590  i)aKis  including  300  full-paije  plates  in 
black  and  colors,  coiitainiii!,' 'i.sij  lij^urcs.  I)e  luxe  binding,  $10,  net. 
The  njvstt'rics  of  the  Peritoneum  ancl  Abdnninal  Cavity  |)articularly 
concern  anatomists,  sur>(eons,  gynecologists  and  obstetricians,  and  in- 
terest the  i,fenenil  i)ractitioner  to  a  degree  scarcely  less.  This  compre- 
hensive and  authoritative  work  will  therefi;re  a})peiil  to  an  unnsuaiiy 
wide  constituency  of  readers.  Dr.  Huntington  V.as  approached  the  sul)- 
ject  in  the  lii,'iil  tnrown  upon  it  liy  eniliryoloi,'y  and  ^omparative  anatomy, 
thereliy  clarifying  the  hitherto  diliieult  and  complicated  morphological 
|)r(>l)lems  preseiiti'd  l)y  these  regions.  The  hook  is  uni(|iie  in  its  marvelous 
wealth  of  illustrations,  amounting  nracticaliy  to  an  Atlas,  with  fuil  ex- 
planatory text.  Th"  structural  details  of  the  Human  Cacum  and 
Appendix  are  considered  very  fully  by  reason  of  tlu;  extensive  material 
available  and   the  paramount  clinical    importance  of  these  suiyects. 

HYDK  (.FAMKS   NKVINS)   AM)   ]>10NT<;0M1:RY   (V\  H.)     A 

PRACTICAL  TREATISE  ON  DISEASES  OF  THE  SKIN.  Sixth 
edition,  thoroughly  revised.  Octavo,  832  pages,  with  107  engrav- 
ings and  27  full-page  plates,  !)  of  which  are  colored.  Cloth, $4.50,  net; 
leather,  $5.50,  net;  half  Morocco,  $().O0,  iift. 

This  is  beyond  doubt  the  most  A  complete  exposition  of  our 
successful  work  on  skin  diseases,  knowledge  of  cutaneous  medicine  as 
This  work  is  now  looked  upon  as  ]  it  exists  to-day.  The  teaching  in- 
tlie  American  authority. — St.  Lohik  \  culcated  throughout  is  sound  as  well 
Mf.lical  n,ul  NKrfiical  Journal.  as   practical. — The  American  Jour- 


The  first  American  ^  txi-hook.—  ^ '>^^''^  ^f  (.he  Medical  Sciencet. 
Xorthwrfitrru  Ixuirit.  It  is   the   best    one-volume  work 

The  work  answers  the  needs  of  the  ,  tli'it  we   know.—  Virginia  Medical 
general  practitioner,  the  specialist,    ''*"'^' "-"'"' '"'y- 

and   the  student. — Tkr  Ohio   Med-       A   full  and   thoroughly    modern 
ieal  Journal.  text-book    on     dermatology.  —  The 

A   treatise  of  exceptional    merit    Pittsburg  31ediud  Revieiv. 
characterized  by  conscientious  care       The  most  practical  handbook  on 
and    scientific    accuracty.  —  Jiu/Jalo    dermatology  with  which  we  are  ac- 
Medieal  a)id  Suri/iral  Journal.  quainted. —  Chicago  Med.  Recorder. 

JACKSON  (GEORGE   THOMAS).     THE    READY-REFERENCE 

HANDBOOK   OF   DISEASES  OF    THE    SKIN.     Fourth  edition. 

In  one  12mo.  volume  of  617  pages  with  82  illustrations  and  3  colored 

plates.     Cloth,  $2.7."),  vet. 

Without  doubt  forms  one  of  the       The   work   is  especially   rich   in 

best  guides  for  the  beginner  in  der-    forniuhe  and  practical  methods  of 

matology  that  is  to  be  found  in  the    treatment. — Medicine. 

English  language. — Medicin\  \ 

JAMIESON  (W.  AIiLA^).  DISEASES  OF  THE  SKIN.  Third 
edition.  In  one  octavo  volume  ot  656  pages,  with  1  engraving  and  9 
double-page  chromo-lithographio  plates.    Cloth,  $6. 

.IKWETT    (CHARLES).      THE    PRACTICE    OF   OBSTETRICS. 

By  American  Authors.  Second  edition.  Octavo,  77")  pages,  with 
445  engravings  in  black  and  colors,  and  35  full-page  colored 
plates.  Cloth,  $5.00,  net ;  leather,  $().0(),  net ;  half  Morocco,  $»;.50,  net. 

furnishes  a  concise,  comprehensive 


The  most  complete  of  the  recent 
obstetric  text-books  The  illustra- 
tions are  superb  and  possess  the  merit 
of  clearness  and  accuracy. — Jiujjalo 
Medical  and  Surgical  Journal. 

It  is  pre-eminently  a  practical 
treatise  suited  to  the  needs  of  medical 
clauses,  while,  at  the  same  time,  it 


and  trustworthy  guide  to  the  prac- 
titioner. We  regard  this  as  being 
one  of  the  most  scientific  and 
thoroughly  modern  treatises  upon 
this  irn))ortaiit  sriiject  in  useto-oay. 
— .1 ///('/•.  (i !/iieco  ■H/ierd  anil  (Htstet- 
rical  Juurnid. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     17 


JEWETT  (CHARIiES).  ESSENTIALS  OF  OBSTETRICS.    Si-coiid 

edition.     In  one  12tno.  volume  of  385  pages,  with  80  engiiivi'tgs  and 

.')  colored  plates.     Cloth,  $2.25,  net. 

This  is  the  best  epitome  of  ol)stPt-    students  and  j)raetitionersand  to  lee- 

rics  with  which  we  are  familiar.     It  ;  turers  who  need  to  review   salient 

is  sntticiently   illustrated   to   make    pointsofolistctrics  in  preparinii  their 

clear  its  text.     Its  contents  are  well    instruction. — The  A  mrricdii  .1  ounuil 

selected.    It  can  be  recommended  to    of  the  Mrdicul  Sri(iin;<. 

JULER  (HENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE 
AND  PRACTICE.  New  (.Hrd)  edition.  In  one  octavo  volume  of  7;iS  pp., 
with  1!'0  engravings,  25  chromo-lithographic  plates.    Cloth,  s5.25,  /((/. 

KELLY  (A.  O.  ,I.j.  A  MANUAL  OF  THE  PRACTICE  OF  MEDI- 
CINE.    Octavo,  about  (iOO  pages,  illustrated.     Pnpurituj. 

KIEPE  (EDWARD  J.).     AN  EPITOME  OF  MATERIA  MEDICA 

AND  THERAPEUTICS.  See  lint's  Srrirs„f  Mrdical  /'Jpitomcs,^.  is. 

KINO  (A.  P.  A.).  A  MANUAL  OF  OBSTETRICS.  New  (!»tii)  edition.  In 
one  12mo.  volume  of  621)  pages,  with  275  illustrations.  Cloth,  $2.50,  7ief. 
The  bestmanual  thiit  li;isever  been  The  most  succinct,  reliable  andat 
oti'ered  tons.  It  has  a  wonderful  the  same  time  individual  book  for  a 
fund  of  information  in  •:  very  small  student  or  practitioner. — Mitlical 
space. — A'.  O.  Mai.  (uid  Sunj.  Jour.    Xnrs. 

KIRK  (EDWARD  C).  OPERATIVE  DENTISTRY.  See  Ameri- 
can Text-Books  of  Dentistry,  page  2. 

KLEIN   (E.).      ELEMENTS    OF  HISTOLOGY.      Fifth   edition.      In 

one   12mo.   volume  of  506  pages,  with  296  engravings.     Cloth,  $2.0U, 

net.     See  Student's  Series  of  Manuals,  page  27. 

It  is  the  most  complete  and  con-        This  work  deservedly  occupies  a 

cise  work  of  the  kind  that  has   yet    first   place   as  a  text-book  on    his- 

emanated  from  the  press. — Med.  Age.    tology. — Canadian  Practitioner. 

KOPLIK     (HENRY).       THE     DISEASES     OF    INFANCY    AND 

CHILDHOOD.  Octavo,  <)75  pages  with  16ii  engruv^igs,  and  '62 
plates  i.  black  and  colors.  Cloth,  .■^.").00,  //(/ ;  leather,  .■<(). (H),  net. 
Certainly  the  best  book  for  stu-  with  the  treatment,  which  is  not 
dents  we  have  seen  for  some  tiu'e,  as  complex,  but  simple  and  positive, 
it  is  clear,  concise,  ejjigrammatie  ind  with  proper  reyani  to  dosage,  so 
certain  to  make  an  imj)ression  on  often  neglected  in  books  of  this  kind, 
the  mind  of  the  reader.  It  is  fully  to  the  detriment  of  the  student. — 
up  to  date.     We  are  specially  pleased    Chicago  Medical  Record. 

LANDIS  (HENRY  G.).  THE  MANAGEMENT  OF  LABOR.   In  one 

handsome  12mo.  volume  of  329  pages,  with  28  illus.   Cloth,  $1.75. 

liEA  (HENRY  C).  A  HISTORY  OF  AURICULAR  CONFESSION 
AND  INDULGENCES  IN  THE  LATIN  CHURCH.  In  three 
octavo  volumes  of  about  500  pages  each.     Per  volume,  cloth,  $3.00. 

CHAPTERS  FROM  THE  RELIGIOUS  HISTORY  OF  SPAIN  ; 

CENSORSHIP  OF  THE  PRESS;  MYSTICS  AND  ILLUMINA- 
TI  OF  THE  J:NDEM0NIADAS  ;  EL  SANTO  NI^O  DE  LA 
GUARDIA.     12rao.,  522  pages.     Cloth,  $2  50. 

THE  MORISCOS  OF  SPAIN,  THEIR  CONVERSION  AND  EX- 
PULSION. In  one  roval  12mo.  volume  of  425  pages.  Cloth,  $2.25,  net. 

SUPERSTITION   AND   FORCE;  ESSAYS  ON  THE  WAGER 

OF  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL  AND 
TORTURE.  Fourth  edition,  thoroughly  revised.  In  one  hand- 
some royal  12rao.  volume  of  629  pages.     Cloth,  $2.75. 

STUDIES  IN  CHURCH  HISTORY.     The  Rise  of  the  Temporal 

Power — Benef''  of  Clergy — Excommunication.  New  edition.  In  one 
handsome  12m(i    /olume  of  605  pages.     Cloth,  $2.50. 


18     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


Iil<:A'S  HKRII<]S  OF  MI'IDK'AIi  KPITO^IFS.  Ivlited  by  \  K  roi; 
C.  Pkdkkskn,  M.I).  Coverinj,' tilt'  entire  field  of  niediciiie  and  sur- 
gery in  twenty-two  convenient  volumes  i)f  idxiut  2'>i)  pages  each, 
amply  illustrated  and  written  by  jtroininent  teachers  and  specialists. 
Compendious,  authoritative  and  modern.  Following  each  (diapter 
is  a  series  of  ([uestions  which  will  be  found  convenient  in  (|uizzint;. 
Price  per  volume,  cloth,  $1,  tid.  The  following  vrduniesarenow  ready: 
]Ia[.K's  Anatomy  (JUKNTHKlts'  Phyk.iology.  McGlaxna.n's  Phys- 
ics and  Inorganic  Chemistry.  M(  (  Ii.annan's  Organic  and  Phys- 
iological Chemistry.  Na(;kl's  Nervous  and  Mental  Disea.scs. 
Watiii;n's  Histology.  Akchinakk's  I'acteriology  and  Microscopy. 
MA(ii:K  iV:  .Iohnso.n'.s  Surgery.  Ai.mnm;  and  (iKiri'KN  on  the  Kye 
and  Kar.  SciiMIiri'.s  ( ienito-Urinary  «nd  Venereal  Diseases. 
Sciiali:k's  Dermatology.  Manto.ns  Obstetrics.  Tii,i:y'.s  I'edi- 
atrics.  DwKiin's  Jurisprudence.  DwKiiiT'.s  Toxicology. 
Tlie  following  volunus  are  in  press:  KiKl'K's  Materia  Medica  and 
Therapeutics.  Dayton's  Practice  of  Medicine.  Hoi, lis'  Medical 
Diagnosis.  Akniiili.'s  Clinical  Diagnosis  and  Urinalysis.  .Stkn- 
HorsE's  Pathology.  FKUiii'soN  on  the  Nose  and  Throat!  Pkukkskn 
and  Pahkkr's  Gynecology. 

liEA'S  SKRIES  OF  POCKET  TEXT-BOOKS,  edited  by  Bern 
B.  Gallaudet,  M.  D.  (^vering  the  entire  field  of  Medicine  iu  a 
series  of  !?<  very  handsome  l2ino.  volumes  of  350-525  pages  each, 
profusely  illustrated.  (Compendious,  clear,  trustworthy  and  modern. 
The  following  volumes  are  now  ready  : 

Rockwell's  Anatomy.  Collins  and  Rockwell's  Physiology. 
Maktin  and  Rockwell's  (^Chemistry  and  Physics.  Nichols  and 
Vale's  Histology  and  Pathology.  ScHLKiF's  Materia  Medica,  Thera- 
peutics, Medical  Latin,  etc.  MALSiiAiiY's  Practice  of  Medicine. 
Potts'  Nervous  and  Mental  Di8ea.ses.  Hay'OEN's  Venereal  Diseases. 
Gkindon's  Dermatology.  Ballencek  and  Witpehn's  Diseases  of 
the  Eye,  Ear,  Throat  aiid  Nose.  Evans'  Obstetrics.  Crockett's 
Gynecology.  Tuttle's  Diseases  of  Children.  Za  pefe's  Bacteriology. 
The  following  volumes  are  in  press  :  Collins  and  Da  vis'  Diagnosis  ; 
Gallaidet's  Surgery ;  Wk^ks'  Nursing  and  Hamilton's  Massage. 

For  prices  and  separate  notices  see  under  various  authors'  names. 

liEFEVRE  (EGBERT).     A  TEXT-BOOK  OF  PHYSICAL  DIAG- 
NOSIS.    In  one  12mo.  volume  of  450   pages, with  74  engravings  and 
12  plates.     Cloth,  $2.2.".,  Hrf. 
This  book  will  take  front  rank,    tailed  attention,  and  the  same  nieth- 
It  is  prepared  by  a  teacher  of  ex-    ods  as  applied  to  the  thora.x  are  em- 
perience  and  a  clinician  of  acconi-    ployed  and  explained  with  the  varia- 
{)lishment.     Le  Fevre  gives  adequate    tions  ncx'essary.     A    number  of  en- 
instructicm  upon   all  the  details  of   graviuars  and  .\-ray  plates  elucidate 
diagnosis.    The  abdomen  receives  de-    the  text. — liiijjnio  Medical  Jniirnnl. 

I^iONG   (Elil  H.).     A  MANUAL  OF  DENTAL  MATERL\  MEDICA 
AND  THERAPEUTICS.     12mo,  ;!21  pages,  with  (5  engravings  and 
IS  plates.     Cloth,  s3.(iO,  nrt. 
The  author's  aim  lias  been  to  cover  what  is  essential  ;  to  treat  fully  all 
remedies  that  belong  properly  to  the  special   field  of  dental  medicine;  to 
discuss  brietly  the  action  and  application  of  the  most  important  general 
remedies,  emphasizing  tliose  of  which  the  action  may  avail  in  dental  dis- 
eases and  emergencies,  and  to  furnish  matter  for  reference  that  will  cover 
all  ordinary  demands  of  the  dental  student  and  practitioner  as  to  genernl 
remedies,  their   preparations,  do.ses  and  uses.     The  value  of  the  work  is 
much    enhanced    by   the    extensive    Index    of    Drugs,    including    every 
drug  of  local  or  general  ii.se  that  the  dentist  may  have  occasion   to  refer 
to.     This  iiide.x  is,  in  fact,  a  geneial  therapeutic  referendum  for  the  den- 
tal practitioner. 


Lka  Brothers  &  Co.,  Philadklphia  and  New  York.     19 


LOOMIS  (AI^PRED  L.)  ANI>  THOMPSON  (W.  GIIjMAN), 
EDITORS.       A   SYSTEM    OF    PKACTK^AL    MEDICINE.       In 

Contributions  l»y  Various  Anu-rii'an  Authors.  In  four  octiivo  vol- 
umes of  about  900  |)iit,'es  eacli,  f;lly  illustrated  in  black  and  colors. 
Per  volume,  cloth,  $5.00,  ml;  leather,  $6. On,  mt;  half  morocco,  $7.0(t, 
/((/.  For  sale  by  subscription  only.  Full  j)ro8pectu8  free  on  applica- 
tion to  the  Publishers. 

LYMAN  (HENRY  M.).     THE  PR.\CTICE  OF  MEDICINE.    Iii  one 

very  handsome  octavo  volume  of  925  pages,  witli  170  engravings. 
Cloth,  $4.75  ;  leather,  $5.75. 

M«-<aiANNAN  (A.).  AN  El'ITOME  OF  IMIYSICS  AND  INOR- 
<iANIC  (JlIEMlSTi  ;.  r2mo.,  L'l.i  p:ii,'es,  illustrated.  Cloth,  $1.00, 
Hit.     See  Ij((is  Scries  nj  Mirliml  !■' i)ilnm<s,  page  1>>. 

AN  El'ITOME  OK  ORCANIC  AND  I'll  YSK  »L0(  IICAL  CHEM- 


ISTRY,    llimo..  'J4«  pages,   illustrated.     Cloth,  $1,  int.     See    Lea's 
iSirics  of  Mrdiail  EiiilnDK s,  j)age  IM. 

.>IAGEE  (.>!.  1).)  ami  .lOHNSON  (WALIiACK).     AN  EPITO.ME 

OF    S(^R(;ERY.       12m(>.,    a:)out  .">00   pages,    with    IMO   engravings. 
Cloth,  ••^l,  /((•/.    Sfinrlhi.    See  Lai's  Srrirs  <>/  Mnlinil  LpilDiiiis,  page  1^. 

MAISCH  (JOHN  M.).     A    MANUAL    OF    ORGANIC    MATF.dA 

MEDICA.     Seventh  edition,  thoroughly  revised  by  11.  C.  C.  M.\KSCH, 

Ph.  G.,  Ph.  D.    In  one  very  handsome  12mo.  volume  of  512  pages,  with 

285  engravings.     Cloth,  $2.50,  net. 

U.sed  as  text-book  in  every  college       The    best  handbook    upon   phar- 

of  pharmacy  in   the   United   States    macognosy  of  any  j)ublished  in  this 

and  recommended   in   medical   col- j  country, — Huston  Med.  &  tinr.Jour. 

leges. — American  Therapist.  \ 

MALSBARY  (GEORGE  E.).  A  POCKET  TEXT-BOOK  OF 
THEORY  AND  PRACTICE  OF  MEDICINE.  In  one  handsome 
12mo.  volume  of  405  i)ages,  with  45  illustrations,  ('loth,  $1.75,  net; 
flexible  red  leatiier,  $2.25,  net.  See  Lea's  Series  of  Pocket  Te.rt- 
books,     page  1<S. 


Will  readily  commend  itself  to 
students  and  busy  practitioners, 
bringing  forward  as  it  does  the  most 


recent  advances  in  medicine  with 
the  best  of  that  which  is  old,  — 
Medical  Review  of  licvien's. 


MANTON  (W.  P.).  AN  EPITOME  OF  01?.- TETRICS,  12mo,  L't;.'. 
patres,  ,S2  lUusirations.  Cloth,  $1.00, /uY.  ><ve  J.((i's  S(rits  oj  Mnli- 
cal  Epitonics.  page  18. 

MAllSH  (HOWARD).  DISE.^SES  OF  THE  JOINTS.  In  one  12mo. 
volume  of  4ti8  pages,  with  64  engravings  and  a  colored  plate.  Cloth,  $2. 
See  Series  of  Clinical  Manuals,  page  25. 

RIARTIN  (EDWARD).  A  MANUAL  OF  SURGICAL  DIAGNOSIS. 
In  one  12mo.  volume  of  about  400  pp.,  fully  illustrated.       Preparing 

MARTIN (WAliTON)  AND  ROCKWELIi  (WM.  H.).  A  POCKET 
TEXT-BOOK  OF  CHEMISTRY  AND  IMIYSICS.  In  one  hand- 
some 12ino.  volume  of  .'?ti(i  pages,  with  \'M  illustrations.  Cloth,  $1..'>0, 
■net ;  limp  leather,  .^2.00,  net.  See  Lea's  Series  of  I'ocket  Te.ct- 
liDoks,  page  18, 
The  work  accurately  reflects  both 

sciences  in    their   [)resent    develoj)- 

ment.    The  arrangement  of  the  mat- 


ter  is  exeellent.      The  Medical  and 
Snn/ical  Monitor. 


20     Lka  Brothers  &  Co.,  Philadelphia  and  Nkw  York. 


MF]l>iC'AL  l<:i»ITO>IK  SERII';S.  Sit  y.<a'.s  Srrirs  „j  Mnlintl 
EpitofiKx,  page  18. 

MEDICAIj  news  pocket  PORMUIiAllY,  see  page  31.'. 

MITCHEIjTi  (S.  WEIR).      CLINICAL  LESSONS  ON  NERVOUS 
DISEASES.     Ill  one  TJiiio.  volume  of  299  pages,  with  19  engravings 
and  2  colored  plates.     Cloth,  $2.50. 
The  hook  treats  of  hysteria,  reciir- ;  contractions,    rotary  movements   in 
rent  melancholia,  disorders  of  sleep,    the    feehle   minded,   etc.     Few   can 
choreic  movements,  false  sensations    speak  with  more  authority  than  the 
of    cold,   ataxia,    hemiplegic    pain,  |  author. —  The  Journal  of  the  A  meri- 
treatment  of  sciatica,  erythromehil-    can  Medical  At8ociutio)i. 
gia,  reflex  ocularneurosis,  hysteric  | 

MITCHELL.  (JOHN  K.).  REMOTE  CONSEQUENCES  OF 
INJURIES  OF  NERVES  AND  THEIR  TREATMENT.  In 
one  handsome  12mo.  volume  of  239  pages,  with  12  illustrations. 
Cloth,  $1.75. 

MORROW  (PRINCE  A.).  SOCIAL  DISEASES  AND  MARRIACiE. 
SOCIAL  PROPHYLAXIS.  Octavo,  .'.itO  pa,tr»s.  doth  $.;.()0,  >ir/. 
J  lint  rrdilji. 

This  subject  has  not  previously  di.seases  which  have  been  introduced 
been  written  upon  in  the  English  into  the  family  life,  and  there  are  no 
language,  and  altiiough  we  are  quite  more  dislns.singtraeedies  than  those 
familiar  with  the  work  of  several  which  follow.  Morrow  discusses 
French  and  Uerman  writers  (m  the  every  possible  phase  of  the  subject, 
relationship  of  8y])hilis  and  gon-  and  he  lias  made  many  timely  sug- 
orrho'ato  marriage,  we  have  nowhere  eestions  wiiich  are  both  helpful  and 
seen  a  more  masterly  presentation  of  hopeful.  This  book  should  be  read 
this  most  important  subject.  There  by  every  physician,  and  there  are  a 
is  probably  no  medical  practitioner  large  number  of  ncm-niedical  readers 
who  does  not  freijuently  have  ocea-  who  might  read  it  with  profit. — St. 
sion  to  see  the  ravages  of  venereal    Paul  Maliail  Jounidl. 

MU88ER  (JOHN  H.).    A  PRACTICAL  TREATISE  ON  MEDICAL 

DIAGNOSIS,  for  Students  and  Physicians.  New  (.')th)  edition,  thor- 
oughly revised.  In  one  octavo  volume  of  1205  pages,  with  ,'^!i.')  en- 
gravings and  63  full-page  colored  plates.  Cloth,  $6.50,  ict;  leather, 
$7..")0,  net;  half  Morocco,  $8.00,  net. 

A  feio  ni>ticcs  o/  the  previons  edition  arc  appended : 


Musser's  Mrdiad  Diagmi.sis  has 
become  the  leading  and  standard 
work  on  its  subject.  In  this  work 
every  accepted  method  of  clinical 
and  bedside  investigation  is  de- 
scribed clearly  and  fully,  and  every 


This  is  the  best  book  on  medical 
diagnosis  published  in  the  English 
language.  In  it  is  found  everything 
relating  to  the  proper  making  of  a 
correct  diagnosis.  It  is  comj)lete, 
practical,  up-to-date, well  illustrated. 


effort  is  made  to  render  the  teachings  well   arranged,   easy   for  reference, 

of  the  book  of  such  practical  nature  and  is  the  best  iiook  on  medical  diag- 

as   to   be   readily   available   to    the  iiosis,  both  for  medical  students  and 

practitiont  r. — M  e  m  }>  h  i  s   Medical  for  practitioners. — Muriflaud  Med- 

Monthlij.  ic(d  J oiinial . 

XA<JEIi  (J.  D.).     AN   EPITOME   OF   NERVOUS    AND    MENTAL 

DISEASES.     IJmo.,   about  250   pages,    illustrated.     Cloth,   SI,  //,/. 
See  /,(7/'.s'  Series  of  Medical  Kjtitomes,  page  18. 


Lka  Brothers  A  Co.,  Phii.adelphia  and  New  York.     21 

NATIONAL  DISPENSATORY.  See  StUle,  Mnitch  &  Cnspari,  p.  27. 

NATIONAIi  FORMUIiARY.  See  Stil/e,  Mnitch  &  Caspar i's  National 
Diapensatorij,  page  27. 

NATIONAL  MEDICAL  DICTIONARY.     See  JiiUiiigs,  page  4. 

NETTLE8HIP  (E.i.  DISEASES  OF  THE  EYE.  Sixtli  .-.lition, 
thoroughly  revised.  In  one  12nio.  volume  of  ,')t)2  pages,  with  I'.iJ 
engravinge,  and  •")  colored  plates,  test-types,  formulse  and  color- 
blindness test.     Cloth,  $2.2".,  utt. 

Tills  work  for  compactness,  practi-  Hy  far  the  best  student's  text-book 

cality  and  clearness  has  no  superior  on  the  subject  of  ophthalmology. — 

in  the  English  language. — Journal  The  C'liniral  Jitrieiv. 
of  Median  f  and  Science. 

NICHOLS  (.lOHN  B.)  AM)  VALE  (V.  P.).  A  POCKET  TEXT- 
BOOK OF  HISTOLOGY  AND  PATHOlAMiY.  In  one  handsome 
12m().  volume  of  452  pages,  with  213  Illustrations.  Cloth,  $1.75,  net : 
flexible  leather,  $2.25,  net.  See  Lea'.'^  Srricn  of  Pocket  Text-hooks, 
page  18. 

Systematically  arranged,   and   in  can  safely  and  conscientiously  rec 

the    highest    degree    Interesting,  omraend    It    to    both    students    atid 

Thoroughly  up  to  dale.     Tlie  book  practitioners.     T'/c  St.  Louis  Medi- 

is  an  exceptionally  good  one.     We  cal  ami  Snr'/icu/  Joimuil. 

NORRIS  (WM.  F.)  AND  OLIVER  (CHAS.  A.).  TEXT-BOOK  OF 

OPHTHALMOLOGY.     In  one  octavo  volume  of  641  pages,  with  357 
engravings  and  5  colored  plates.     Cloth,  $5  ;  leather,  $6. 

It  is   practical   in   its   teachings,  has  ever  been  offered  to  the  Amer- 

We  unreservedly  endorse  it  as  the  ican    medical     public. — Annals    oj 

best,  the  safest  and  the  most  compre-  Ophthalmology  and  Otology, 
hensive  volume  upon  the  subject  thct 

OWEN  (EDMUND).  SURGICAL  DISEASES  OF  CHILDREN. 
In  one  12mo.  volume  of  525  pages,  with  85  engravings  and  4  colored 
plates.     Cloth,  $2.     See  Series  of  Clinical  Manuals,  page  25. 

PARK  (ROSWELL\  l-:i)IT<)R.  A  TREATISE  ON  SURGERY 
BY  AMERICAN  AUTHORS.  Third  edition.  In  one  royal  octavo 
volume  of  1  lOS  pages,  with  ()(t2  engravings  and  64  full-page  plates. 
Cloth,  $7.00, //^/;  leather,  .$s.OO,  >/^/.  vr  republished  also  in  2  vol- 
umes. Vol.  I,  General  Surgery  ami  Surgical  Pathology.  Cloth, 
■^.3.75,  net.  Vol.  II,  Special,  Regional  and  Operative  Surgery. 
Cloth,  .S.75,  net. 

The  work  is  fresh,  clear  and  practi-  clear-cut,  thoroughly    modern    and 

cal,  covering  the  ground  thoroughly  admirably  resourceful. — Johns  Hop- 

yet   briefly,  and   well   arranged  for  kins  Hospital  Bulletin. 
rapid  reft-rence,  so  that  it  will  be  of        The  latest  and  best  work   written 

special  value  tothestudent  and  busy  ui)on  the  science  and  art  of  surgery. 

[)ractitioner.       The     patliology     is  Columh.is  Medical  Journal. 
)road,  clear  and  scientific,  while  the        It  is  thoroughly  practical  and  yet 

suggestions     upon     treatment     are  thoroughly  scientific— J/«(i.  News. 


22     Lka  Brotheks  h  Co.,  Philapblphia  and  New  York. 

PARK  (WILLIAM  H.).     RACTERIOLOCY  IN  MEDICINE  AND 

HFUGKllY.     ll'mo.,  (iSS  pn<,'es,  with  87  illustrations  in    black  and 
colors,  Hnd  'J  jilatcs.     Clotli,  $'■]. 00  net. 

This   hook    tills   a    very   diatinft  of  view  of  the  hyjrienist  and  public 

^a|>.     None  of  the  te\t-l)ooks  in  our  health  ofReer.     TIk;  work  is  correct 

laiiuiiau'e  takt>  up  tin;  subject  of  hac-  and  very  well  up  to  date.      Tkr  Mon- 

teriolouy    so    tlioronLr'>ly     and     no  (real  Mcdiatf  Journal. 
soundly  as  does  this  from  the  point 

pI':i)i:rskn  (\ .  c.i.  am>  pakker  (i:.  o.i.   an  epitome  of 

(rYNE('<  >L< )( i  Y.     See  /.r<i's  So-ics  a/  M((tir,il  F^itllmnrs,  paj,'e  18. 

PEPPER  (A.  J.).  SURGICAL  PATHOLOGY.  In  one  12mo.  volume 
of  TAX  paRes,  with  81  engravings.  Cloth,  ^2.  See  Student's  Series  of 
M<munls,  p.  27. 

PICK  (T.   PICKERING).      FRACTURES  AND  DISLOCATIONS. 

In  one  12mo.  volume  of  5.30  pages,  with  93  engravings.      Cloth,  $2. 
See  Series  of  Clinical  Maniuds,  page  25. 

PliAYPAIR  (W.  S.).  A  TREATISE  ON  THE  SCIENCE  AND 
PRACTICE  OF  MIDWIFERY.  Seventh  American  from  the  ninth 
English  edition.  In  one  octavo  volume  of  700  pages,  with  207 
engravings  and  7  plates.     Cloth,  $3,75  yiet ;  leather,  $4.75,  vet. 

This  work   must   occupy   n  fore-  the  ablest  English-speaking  authori- 

most  place  in  obstetric  medicine  as  ties  on  the  obstetric    art. — Buffalo 

a   safe  guide  to  both  student  and  Medical  and  Surgical  Journal, 
obstetrician.    It  holds  a  place  among 

POCKET  TEXT-BOOKS.   See  page  IS. 

POLITZER  (ADAM).  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE 

EAR    AND    ADJACENT   ORGANS.       New   American    from    the 

f.iurth   German   edition.     In  one  octavo  volume  of  8!i(3   pages,   with 

31()  original  engravings.     Cloth,  $7. r>0,  }ict.    ,J  nxi  ratdij. 

It  is  an  absolute  «?/(c  (/(M  7(0/)  for  '  physician   as  a  book    of   reference 

the   practitioner  who  devotes  atten-    upon     these      toi)ics. — A  invricaii 

tion   to   otology  or    rliinology,   And    Journal  of  tlic  Medical  Sciences, 

should   be   in  the  lil)rary  of  every  | 

POSEY  (W.  C.)  AND  WRIGHT   (JONATHAN),  F]DITORS.     A 

TREATISE  ON  THE  EYE,  NOSE,  THROAT  AND  EAR.  Hy 
Eminent  authorities.  (Octavo,  1243  pages,  richly  ilhiBtrated  with  fi.'iO 
engravings  and  3")  full-page  plates  in  black  and  colors.  Cloth,  .$7.00, 
)ir(;  leather,  .S8.00,  ?)r< :  half  Morocco,  $8.50,  ?(c<. 
Published  also  in  2  volumes.  Volume  I.  Posey  on  the  Eve.  700  pages, 
358  engravings,  !!•  plates.  Cloth,  $4.(10,  net.  Volunie  II.  Wright 
on  the  No.se,  Throat  and  Ear.  543  pages,  292  engravings,  1(5  plates. 
Cloth,  .'^3..")0,  vet. 

The  book  is  a  distinct  success.  It  book  which  every  specialist  should 
will  fulfil  the  aims  of  its  editors  and  own,  because  he  will  find  in  it  much 
win  popularity  among  students  and  that  cannot  be  found  in  any  other 
practitioners. — .luluis  llopLim^Ilos-  \  work  of  the  kind,  and  tlie  book  that 
liit(d  liulhliii.  !  tiie  general  practitioner  should  pur- 

This  is  the  best  book  published  in  !  chase,  for  it  is  especially  adapted  to 
the  English  language  upon  the  eye,  his  needs,  is  strictly  up-to-date,  and 
ear,  nose  and  thiDat.  In  (his  work  because  he  can  purchase  no  single 
every  chapter  is  exeelb'nt.  The  book  which  will  meet  hiswantRas 
most  recent  theories  iind  methods  of  thoroughly  as  will  this  work. — 
treatment  are  incorporated.     It  is  a    JVorllnrc-itern   Lanal. 


Lka  Brothers  &  Co.,  Philadelphia  and  New    York,      23 


POTTS  (OHARIiKS  S.).  A  I'OCKET  TEXT-1500K  OF  NERVOUS 
AND  MENTAL  DISEASES,  [n  one  Imndsome  12rao.  volum.'  of 
445  pii,t,'es,  with  88  <Mif;riiviiif;s.  Clotli,  $\.7r>,  net ;  limp  Iciither,  $2. 25, 
»r<.     See  Lra's  Srriix  of  Pocket.   'J'e.rl-li(inLt,  pn^v.  ]><. 

Far  superior  to  the  onlinarv  work  slndent  to  inultrstand  the  essential 

of  its  chiss.      The  autlmr  lias  sue-  plan  of  his  future  study.     The  sue- 

eeeded  in  inipnssintr  the  l)road   out-  eccdinf;  ehapterson  the  various  dis- 

lines  of  the  stnieturc  and  functions  eases,  althoufih  co?idensed,  are  iiecu- 

of  the  nervous  system  so  sinipl\  and  rate  and  up-to-date,  and  give  in    u 

so  coniprehenfqvely,  with    the    aid  few  word.s  the  most  important  faets. 


)f  a  few  well-seh'eted  dia>i;rams,  as    — linsloii  Midlnil  (iinl  Sunilrol ,1  mn 
to  make  it  compralively  easy  for  the    noL 

A  TE.VTBOOK  ON   MKDI('Ar>  .\XD  SI  KCICAL  EIKCTHI- 


CITV.     Octavo,  about  .S'lO  pages,  limply  illustrated.     Shoilly. 
PROGRESSIVE   MEDICINE.     See  page  32. 

PURDY  (CHARIiES  W.).  BRIGHT'S  DISEASE  AND  ALLIED 
AFFECTIONS  OF  THE  KIDNEY.  In  one  octavo  volume  of  288 
pages,  with  18  en^avings.     Cloth,  $2. 

PYE-SMITH  (PHIIilP  H.).  DISEASKS  OF  THE  SKIN.  In  one 
12mo.  vol.  of  407  pp.,  with  28  illus.,  18  of  which  are  colored.  Cloth,  $2, 

RALPE    (CHARLES   H.).      CLINICAL      CHEMISTRY.      In    one 

12nio.  volume  of  314  pages,  with  l(i  engravings.     Cloth,  $1.50.     See 
Student's  Series  of  Mamuils,  page  27. 

REMSEN  (LRA).  THE  PRINCIPLES  OF  THEORETICAL  CHEM- 
ISTRY. Fifth  edition,  thoroughlv  revised.  In  one  12nio.  vol- 
ume of  326  i)ages.     Cloth,  $2. 

REYNOIiDS  (EDWARD)  AM)  NEWEM.  (F.  S.).  A  MANUAL 
OF  PRACTICAL  OHSTK/I'RICS.  Second  and  revised  edition. 
Octavo,  531  pa.i,'es,  illustrated  with  253  engraviuLrs,  and  3  plates. 
Cloth,  $3.75,  jif/. 

A  complete  text-book  on  ohstetrics,  '  so  complete,  diagnostic  jioinls  so 
characterized  by  a  distinct  aceen-  clearly  brought  out,  and  the  line  of 
tuatioii  of  the  practical  side  of  this  treatment  of  special  conditums  so 
science. —  I iiltrstdh  Alcdicul Jniiriuil .    graphically    drawn. — 'llw    \' irj/inid 

Seld<mi  have  we  found  descriptions    Midiml  Srnn'-Motiflih/. 

RICHARDSON  (BENJAMIN  WARD).  PREVENTIVE  MEDI- 
CINE.    In  one  octavo  volume  of  729  pages.     Cloth,  $4. 

ROBERTS  (JOHN  B.).  THE  PRINCIPLES  AND  PRACTICE  OF 
MODERN  SURGERY.  Second  and  revised  edition.  ( )ct?\vo,  838  pages 
with  473  engravings  and  S  plates.  Cloth,  $4  iT),  net;  leather,  $5.25,  net. 

A   clear,  concise,   comprehensive    satisfactory  or  valuable  single  vol- 
and   practical   presentation    of   the    uine  work  on  this  subject. — Panjic 
most  modern  surgery.     The  student     Mcdivu/  Jonnnil. 
or  practitioner  will  not  tiud  a  more  i 

ROBERTS  (SIR  AVIIilJAM).  A  PRACTICAL  TREATISE  ON 
URINARY  AND  RENAL  DISEASES.  INCLUDING  URINARY 
DEPOSITS.  Fourth  American  from  the  fourth  London  edition.  In 
one  very  handsome  8vo.  vol.  of  609  j))).,  with  81  illus.     Cloth,  $3.50. 


24     Lka  Brothers  «^  Co.,  Thiladrlphia  and  New  York. 

IlOrKWKLIi.  (W.  Hm  .Ir.).  A  POCKET  TEXT-MOOK  OF  AN- 
ATOMY. 12in().,  tloO  paRcs,  illustrated,  (^lotli,  .*-'.2r),  nrl  •  limp 
leather.  $2.75,  nrt.       Sec  Lrn\  Scrirs  oj  Farkrl  'I  rxt-bonlc.s,  page  18. 

An  excellent  example  of  skilful  eiiitomi/.ntinn.  A  compendions  text- 
book for  the  stndcnt  and  ai|uick,  hanily  work  of  ret'crenee  for  the  physician 
or  .MiirKeon.     E.xaetly  adapted  to  llie  needs  of  trtiiiiing  schools  for  nurses. 

RO<;h:R  (<J.  H.).  INFECTIOUS  DISEASES.  Translated  hy  M.  S. 
Gahriel,  M.I).  Octavo.  ,S(;4  pa^e.s,  41  illu.strations.  Cloth,  $."■)  75  /"/. 
./m.s7  rcddi/. 

Symptoms,  pathology,  diagnosis,  !  fore  of  all  things  connected  with  in- 
prou'nnsjs  and  treatment  are  con  I'eetious  diseases.  Abont  t\v<i  hun- 
sidered  fully  and  practically.  The  drcd  pages  are  devoted  to  treatment, 
liook  is  the  work  of  a  practical  man  which  is  presented  in  a  manner  that 
who  works  from  a  .scientific  basis—  is  at  once  novel  and  yet  eminently 
one  who  knows  the  why  and  where-    practical. — '/'he  Medical  Standard. 

ROSS  (JAMES).  A  HANDBOOK  OF  THE  DISEASES  OF  THE 
NERVOUS  SYSTEM.  In  one  hand.some  octavo  volume  of  726  pages, 
with  184  engravings.     Cloth,  $4.50 ;  leather,  $5.50. 

8CHAFER  (EDWARD  A.).  THE  ESSENTIALS  OF  HISTOL- 
OGY. DESCRIPTIVE  AND  PRACTICAL.  Sixth  edition.  Octavo, 
42(i  i)agefl,  with  4t).'i  illustrations,     Cloth,  .-^.'{.rto,  iit't. 

Thi'  most  satisfactory  elementary  lish  language. — The  liuxton  Mcdiad 
text-book  of  histology  in  the   F^ng-    (tiid  Sunjical  Journal. 

A   COURSE   OF   PRACTICAL    HISTOLOGY.    Second  edition. 


In  one  12mo.  volume  of  307  pages,  with  59  engravings.   Cloth,  $2.25. 

SCHALEK  (A.).  AN  EPITOME  OF  SKIN  DISEASES.  12mo., 
225  pages,  o4  engravings.  Clotli,  $1  .Oo,  7ut.  See  Lea's  Series  oj  Med- 
ical F.pitoiiics,  page  IS. 

SCHIiEIF  (WILIilAM).  MATEItTA  MEDICA,  THERAPEUTICS, 
PRESCRIPTION  WlilTlNG,  MEDICAL  LATIN,  ETC.  Second 
and  revised  edition.  r2mo.,  370  pages.  Cloth,  .-^1.7"i;  limp  leather, 
S2.25,  7ict.     See  Lea's  Series  of  Pocket  Text-hooks,  page  IS. 

It  contains  in  a  concise,  definite,  pletecollege  courses  on  Materia  Med- 
and  assimilable  form  the  essential  ica  and  Therapeutics. — The  National 
knowledge  required  in  the  most  com-  •  Medical  Review. 

SCHMAUS  (HANS)  AND  EWING  (JAMES).  PATHOLOGY 
AND  P.\THOLO(;iCAL  ANATOMY.  Sixtii  edition.  Octavo,  (i02 
pages,  with  351  engravings  and  34  plates  in  black  and  colors. 
Cloth,  ?;4.00,  net. 

This  work   embodies  all   tiie   re-    additions    and    editorial    work    by 
search    of  tlie    l)est   European    and     Professor  lOwing    render    the    book 
.American  observers,  and  is  without ;  all    the     more     valuable. — Medical 
a  superior,  if  indeed  it  has  an  eipial.    Profp-ess. 
in  this  or  any  other  language.     The 

SCH>III)T  (liOUIS  E.).     A\   EPITOME  OF    (iKN  ITO-UKINARY 

AND  VENEREAL  DISEASES.     l2mo.,  21!i  pa-res,  21   cnuravings. 
Clotli,  .'^l,  net.     See  Iau's  Scries  i>j  Mcdiad  I'Jiiiliinics,  page   18. 


Lka  Bbothkeh  &  Co.,  Phii.adki.pmia  and  New  York.     25 

SENN  (NICHOLAS).  SURGirAL  BACTERIOLOGY.  Second  edi- 
tion, lu  one  octavo  volume  of  2t>S  pa^es,  with  I'.i  i)lateH,  10  of  which 
are  colored,  and  !)  engravings.     Cloth,  $2. 

SERUCS  OP  CLINICALj  MANUAIjS.  A  Series  of  Authoritative 
Monograj)hs  on  Important  Clinical  Subjects.  Tiie  foUowiiij,'  volumes 
iiri' now  leady  :  Cai;i'KK  and  Fkost'.s  Ophthalmic  Surgery,  $2.25; 
Maksh  on  Diseases  of  the  Joints,  $2;  OwKN  on  Surgical  Diseases  of 
Children,  $2;  I'lCK  on  Fractures  and  Dislocations,  $2. 

For  separate  notices,  see  under  various  authors'  names. 
SERIES  OP  MEI»I('AL  EPITOMl<;S.    See  page  18. 

SERUMS  OF  POCKET  TEXT-BOOKS.     St  <>  page  18. 

SERIES  OF  ST  ATI:    IM)ARi)   E\A>li\ATiON   t^UESTIONS. 

See  page  20. 

SIMON  (CHARIiES  E.).  A  TEXT-BOOK  ON  PIIYSKM.OGICAL 
CHEMISTRY.  Octavo,  4.")3  i)a,i,'cs.     Clotii.  $;5.2.'),  net. 

Tills  book  is  a  dcservintj;  ooinpiin-  clan.    Simon  has  honored  Anieriean 

ion  work  to  Simofi's  Ciininil  Ding-  medicitu-  in  his  pioneer  work  in  a 

7insis,  and  like    it  will    live   to    l>f-  fii-lil  which   heretofore  has  been  oc- 

oome    a    standard    and    recognized  enpied    by     foreiyn     authors.  — 77//' 

te.xt-ltook  for  students,  and  a  guide  Mrdicnl  Furtiiliililhi. 
for    the    thoui^ditful    studeMt-ph\  si- 

SIMON  (CHARL.es  E.).  CLINICAL  DIAGNOSIS,  BY  MICRO- 
SCOPICAL AND  CHEMICAL  METHODS.  New  (5th)  and  revised 
edition.  In  one  octavo  volume  of  ()95  pages,  with  150  engravings  and 
22  full-page  colored  plates.     Cloth,  $4.00,  net.     JnsI  nadi/. 

A  few  notices  oj  the  previous  editions  are  (tppended. 

This  book  thoroughly  deserves  its  ;  The  chapter  on  examination  of 
success.  It  is  a  very  complete,  authen-  the  urine  is  the  most  complete  and 
tic  and  useful  manual  of  the  micro-  advanced  that  we  know  of  in  the 
scopical  and  chemical  methods  [  English  language. — Canadian  Pruc- 
which  are  employed  in  diagnosis,  j  ^(7(«HPr. 
— A'.  Y.  Med.  Journal  I 

SIMON  (WM.).     MANUAL  OF  CHEMISTRY.    A  Guide  to  Lectures 

and  Laboratory  Work  in  Chemistry.     A  Text-book  specially  adapted 

for  Students  of  Pharmacy  and  Medicine.     Seventh  edition.     In  one 

8vo  volume  of  613  pages,  with  M  engravings  and  8  plates  showing 

colors  of  64  tests,  and  a  sj)ectra  plate.  Cloth,  $3.00,  net. 

It  is  difficult  to  see   how  a  better    students.     It  is  clearly  written  and 

book  could  be  constructed.     No  num  I  beautifully  and  instructively  illus- 

who  devotes  himself  to  the  practice    trated.     The  fre(|uent  new  editions 

of  medicine  need  know  more  about  !  that  are  called  for  allow  the  work  to 


chemistry  than  is  contained  between 
the  covers  of  this  book. —  The  North- 
western Lancet. 

Si/non'.s  Chrniistrij  has  long  been 
a  favorite   with   teachers  and  with 


be  kept  up  to  the  latest  researches. 
As  a  text-book  for  medical  students 
it  has  no  sujtenor. —  Dearer  Medieid 
'I'  iines. 


SliADE   (D.   D.).     DIPHTHERIA;    ITS    NATURE    AND    TREAT- 
MENT. Second  edition.  lu  one  royal  12mo.  vol.,  158  pp.   Cloth,  $1.25. 


26       LKA    BKOTMKKH  «fe  Co.,    I'HII.ADKLI'MIA    AND   NKW    YoKK. 


SMITH  i.I.  lil^^WIH).  A  TIIKATISK  ON  TlIK  DISKASKS  OF  IN- 
KAN(;Y  and  CIIILIUIOOI).  Ki-hth  edition,  liion.iiglily  revist'd 
aiitl  rewrittt'ii  and  much  enlaiKi'd.  In  one  larjje  Kvo.  volume  of  W.i 
j)af,'es,  witli  '27.5  engravings  and  4  fuil-jiai;e  piates.  Oloth,  $4.r)(); 
leather,  '^Ft.'ti). 

For  years  the  leadini(  text-book  on  A  safe  ijuide  for  students  and  |>hy- 
chiidren'H  diseases  in  America. —  sieians. —  The .'  in.,li>itr.oj'  Obstetiiia. 
Vhiciujo  Medical  Recorder. 

SMITH  (STKPHKN).  OI'KKATIVF  SURGKRY.  Second  and  thor- 
oughly revised  edition.  In  oue  octavo  volume  of  892  pages,  with 
1005  engraving,s.     l^loth,  $4. 

One  of  the  most  satisfactory  works  1  dium  for  the  modern  surgeon. — Hot- 
on   modern   operative    surgery    \'iti\toii  Medical  mtd  SargicalJonrnal. 
puhlislu'd.      The  book  is  a  compen-  | 

SOIiliY  (S.  l-:i)WIN).  A  HANDBOOK  OF  MKI)I(L\L  CLIMA- 
TOIvOtiY.  In  one  handsome  octavo  volume  of  4tlJ  pages,  with  en- 
gravings ami  11  full-page  plates,  5  of  which  are  in  colors.  Cloth,  $4.(10. 

A  clear  and  lucid  summary  of  to  its  iiitluence  u]>on  human  beings, 
what  i.«  kmtwn  of  cliimite  in  relation  '  — The  Therapeutic  ikizetle. 

STAKK  |>i.  Aiilii:\).     A  TRFATISF  ON  OIKJANK^  NFRVoUS 

DISFASKS.     ( »ctavo,  7  10  l>agi's,  27r)engravingsand  2t!  colored  plates. 
Cloth,  .Stl.OO.  iii1\  leather,  $7.0(1,  ml:  half  Morocco,  $7.50,  net. 

The  besi  book  on  organic  nervous 


It  is  gratifying  to  tiolicc  thai 
special  care  has  been  exeici.'^ed 
(hroui^hout  (he  book  to  give  prom- 
inence to  the(|uestion  of  treatment. 
It  deserves  to  lake  its  place  among 
the  best  text  books  in  English  upon 
diseases  of  the  nervous  system.  - 
Jiilnis  Hoji/.in.s  llosiiildl  liiillitiii. 

Especially  in  regard  to  treatment 
the  statements  are  full  and  precise,  i  .Ury/Zcu/ ./ 
— Clcvdmid  Ml  ilical  .foiiriKd.  I 


diseases. —  llnfjidn  Mniicid  .1  niinnil , 
This  book  is  easily  the  best  that 
has  appeared  in  America.  l"or  the 
student  it  is  especially  to  be  recom- 
mended and  for  the  neurologist  it 
j)resents  in  a  brief  and  in  ii  very 
attractive  way  the  conclusions  of  a 
vtTV  wide  e.\|)erience, — InlirKtatc 
uniiil . 


sTATi<:  novRi)  i:.vami\atio\si<:hies.   (  i.assified  and 

EDITED  I'.V  H.  .1.  E.  SCOTT,  A.M.,  M.D.  Containing,  with 
answers  or  references,  every  (luestion  asked  at  all  of  the  examinations 
held  by  the  New  York  State  Hoard  of  Medical  Examiners.  The  best 
guides" to  similar  examinations  in  other  States.  In  7  volumes,  bound  in 
llexible  cloth,  each  containing  from  'JOO  to  ,S(i0  I'Jmo.  ])ages,  i)rinled 
on  paper  suitable  for  either  pen  or  pencil,  every  other  page,  opposite 
text,  being  left  blank  for  memoranda.  Price,  $1.50  per  volume. 
The  respective  volumes  cover  the  subjects  of  Anatomy,  (rradij), 
Chemistry,  {rcudi)),  Obstetrics,  (midi/),  Surgery,  (niidif),  Practice, 
Materia  Mediea  and  Therapeutics,  (rcudi/),  Pathology  and  Diagnosis, 
{rriidji),  Physiology  and  IIygi<iie,  (imitariiH/). 

STEXHOUSE  (JOH\).     AN  EPITOME    OF     PATIIOLOOY.      See 

l.ca's  Series  <ij  Medical  K i>iliniies,  ])age  IS. 

STIIjIiE  ( AliFRED).  CHOLERA  ;  ITS  ORIGIN,  HISTORY,  CAUS- 
ATION, SYMPTOMS,  LP]SIONS,  PREVENTION  AND  TREAT- 
MENT. In  one  12mo.  volume  of  16;^  pages,  with  a  chart  showing 
routes  of  previous  epidemics.     Cloth,  $1.25. 

THERAPEUTICS   AND    MATERIA    MEDICA.      Fourth    and 

revised  edition.  In  two  octavo  volumes,  coutainiug  1936  pages. 
Cloth,  $10;  leather,  $12. 


Lka  Bkothkhh  &  Co.,  PhiladkM'hia  AM)  Nkw  York.     27 


STIIiLK  (AliFllEI*),  MAIHCH  JOHN  M.)  ANI»  <'ASPAKI 
(CHAS.  JR.).  rilK  NATIONAL  l>lSI'KNSATnKY:  ("oMtaiiiiiiK 
till'  Natural  llistoiv,  < 'litriiistrv,  riiariiiacy,  Aftioiis  and  rs»'.s  oC 
Medicines,  incliidiiii,'  those  reeojinized  in  t)ie  late.st  I'liarnuicoineiaH  of 
the  Unitecl  Stiite.s,  (ireat  Britain  and  (lerniany,  with  nuniernns  refer- 
ences to  the  Freneh  ("odex.  Fifth  edition,'  revised  and  enlar^jed, 
including,'  the  U.  S.  I'hartnaeopa'ia,  Seventh  Deeennial  Revision. 
With  .Supplement  containini;  the  Natioiml  Forninlary.  In  one 
nuiijnifK'ent  imperial  ()ctavd  volume  of  ahout  l.'(llir»  pages,  with 
.'{liO  engraving's.  Cloth,  $7.L'r>;  leather,  $8.  With  ready  reference 
Thunih-letter  Index.     Cloth,  $7. 7a  ;  leather,  $HMK 

STIMSONiLiEWIS  A.).    A  MANUAL  OF  OPKRATl  VK  SUUtiKKY. 

Fourth  ed.'*'"ii.     In  one  royal   I'Jmo.  volume  of  oM   pages,  with  •-!',»;{ 
engravings.     Cloth,  $;{.0(t,  lui. 

The  hook  is  worth  the  priee  for  the  every  particular.     It  covers  the  field 

illustrations    alone. —  0/iio   Medical  so  ihOrou^hly  as  to  make  it  a   very 

Journal.  valuable     te\t-l)ook     and    a     ready 

Well  wrilteii,  clear,  concise,  prae-  refcrenee-hook   for  surgeons.  — /\(f//- 

tical,  and   tlioroiighly  up-to-date  in  sns  Cihi  Mi  iliml  h'l  f(,,il. 

STIMSON  (liEWIH  A.).      A   TUFATISK   ON    FKACTUUKS    AND 
DISLOCATIONS.      Third   edition.       In   one  hand.xome   (uaavo  vol- 
ume of  842  pages,  with  ;'),■!(;  engravings  and  Wl  plates.     Cloth,  |5.0(), 
*(('/;    leather,  .iiti.oO,  iift ;  half  Morocco,  .iii.')0,  7i'7. 
I'reeiuinetitly    the    authoritative    value.     The   work    is   profusely    il- 
text-hook  upon   the    Hid)jcct.      The    lustrated.     It  will   l)e    found   indis- 
vast  experience  of  the  author  gives    pcnsahle  to  the  stndentand  llie  prac- 
to  his  conclusions  an  unimpeachable    litiouer   alike.  — 7'Ae  Midical  J<jf. 

STUDENT'S  QUIZ  SERIES.  Thirteen  volumes,  convenient,  author- 
itative, well  illustrated,  handsomely  hound  in  clt)th.  1.  Anatomy 
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ogy, Pathology,  and  Bacteriology ;  5.  Materia  Medica  and  Thera- 
peutics ;  G.  Practice  of  Medicine;  7.  Surgery  {double  number);  8.  Genito- 
urinary and  Venereal  Diseases;  9.  Diseases  of  the  Skin;  10.  Disea.ses 
of  the  Eye,  Ear,  Throat  and  Nose;  11.  Obstetrics  ;  12.  Gynecology  ; 
13.  Diseases  of  Children.  Price,  $1  each,  except  Nos.  1  and  7, 
Anatomy  and  ISurgery,  which  being  double  numbers  are  ))riced  at 
$1.75  each.     Full  specimen  circular  on  application  to  jjublishers. 

STUDENT'S  SERIES  OF  MANUAIiS.  12mos.  of  from  ;5()0-r)4() 
pages,  profusely  illustrated,  and  bound  in  red  limp  cloth.  BiacK's 
Materia  Medica  and  Thera))eutics  (sixth  edition),  $1..">().  nil.  Ki, kin's 
Elements  of  Histology  {5th  edition),  $2. (.)(>,  mt  ;  Pl':flM-:u's  Surgical 
Pathology,  $2;  TuEVKs'  Surgical  Applied  Amitomy,  .-;2.(i(),  ml. 
RALFE's'Clinical  Chemistry,  $1.50.  Hkkman's  Firstl.ines  in  Mid- 
wifery, .-^1.2.'). 

For  separate  notices,  see  under  various  author's  names. 

STURGES  (OCTAVIUS).  AN  INTRODUCTION  TO  Til  F  STUDY 
OF  CLINICAL  MEDICINE.     In  one  12mo.  volume.     Cloth,  $1.25. 

SUTER  (W.  NORWOOD).  A  MANUAL  OF  REFRACTION  AND 
MOTILITY.  12ino.,  .{82  pages,  101  engravings,  4  colored  plates. 
Cloth,  $2, /<r/. 

A  text-book  which  can  be  readily  The  work  is  devoid  of  bias,  is  dir.it 

understood    by     the     beginner     in  and  accurate,  and  is  undoubtedly  the 

ophthalmology  and  sutlicieiitly  com-  best    that    has    been    published   in 

plete  to  meet   the    requirements   of  recent  years. — M(difiil  Ix'irnnl. 
advanced  students  and  practitioners. 


'28     Lea  Brothers  d  Co.,  I'uii.ADKi.i'iiiA  and  Nkw  Yurr. 


SUl'l'ON  (JOHN  ItliAND).  SnUJICAI.  I H S K A H KS  OK  TilK 
OVARIK.S  AND  KALLOIMAN  TIIUKS.  IiicliuliiiK'  AlHloiiiiiml 
I'rcgiiaiioy.  In  out-  iL'tiio.  voliiiiif  of  5i:{  pages,  wilh  119  fiigraviiigH 
and  &  colored  pluteH.     Cloth,  $3. 

S'/YMONOWK'Z    (li.)   .\M>    >la(>CTAMilT>I    (.1.   Kill  (i:).       A 

TKXTI!(»(»K  OK  lIlsrol.tMiV  oKTIIKllI'MAN  I'.oDV:  in- 
cluding' MiiTOHcopiciii  'IVclini(|ue.  Octavo,  -l.S?  |>iii,'t'H,  with  277 
orJL'inul  t'liu'iiiviMLrs  and  57  inset  platfs  in  hiack  and  colors,  contain- 
ini,'Hl  fikrnies.     ('Inih,  s4.7."), //</. 

Tills    ho()l<     will    takf    i's    place  adaptid  lor  tcncliinL,'  jtnrposcs  ;  tlie 

ain'Mi^  the  livst  favorites  of  the  tt'Xt  lixt    is   aiicnratr   and    nindern,    ilic 

hooks  on   Wioloy;y. — Joiinml  .1  ///(//-  ilhistralioiisMreexIrenielv  ln-anlifiil, 

lutii  Miiliciil  AKKorintiiin.  well  selected  and  iniinerons.     M nli- 

Eminently   satisfactory    and  well  citl  Jiermd. 

TAIT  (LAW80N).     DISKASKS   OK  WOMKN  AND   ABDOMINAL 

SURGERY.     ( )ctavo,  546  paxes  and  3  plates.    Cloth,  $,'}. 

TAYLOR  (AIjFRKD  8.).  MEDICAL  .IIJRISPRUDENCE.  New 
American  from  the  twelfth  Enj,'liHh  edition,  specially  revised  hy  Cl.AKK 
Bl«:i,L,  Esq.,  of  the  N.  Y.  Har.  In  one  .Svo.  vol.  of  H.'il  pa>,'eH,  with  5-1 
engravings  and  8  full-page  plates.     Cloth, $4.50;  leather, $5.50. 

To  the  student,  asto  the  physician,  he  found  to  he  thorough,  authorita- 

we  would  say,  get    Ttiylur  first,  and  live     and     modern. — Albany     Laiv 

then  add  as  means  and    inclination  Jdunidl. 

tuiihlK  you.— American  Practitioner  |',ol.al)ly  the  hest  work  on  the 
and  News.  suhject  written  in  the  English  Ian- 
It  is  the  authority  accepted  as  guage.  The  work  has  heen  thor- 
dnal  hy  the  courts  of  all  English-  oughly  revised  and  is  up  to  date. — 
speaking  countries.     The  work  will  I'acijic  Medical  Journal. 

TAYLOR  { ROBERT  W.).  (JENITO-URINARY  AND  VENEREAL 
DISEASES  AND  SYPHILIS.  New  (.id)  himI  revised  edition.  In 
one  very  handsome  octavo  volume  of  ahout  750  pages,  with  153  en- 
gravings and  3!*  colored  plates.  Cloth,  $5.00,  net;  leather,  $(I.OO, 
net;  half  morocco,  $0.50,  /((Y.    ./ nsi  rraihi. 

A  jiic  notice!^  (ij  the  prrrious  rdilion  iirr  niijundcd. 

By  long  odds  the  best   work   on        It  is  a  veritable  storehouse  of  our 

venereal  diseases, — Louisville  Medi-  knowledge  of  the  venereal  diseases. 

cal  Monthly.  It  is  commended  as  a  conservative, 

The  clearest,  most  unbiased  and  practical,    full    exposition     of  the 

ably  presented  treatise  as  yet  pub-  greatest    value. —6%»mj^w    Clinical 

lisheu    on    this   vast   subject. —  The  Ji^view. 
Medical  News. 

TAYLOR  (ROBERT  W.).  A  PRACTICAL  TREATISE  ON  SEX- 
UAL DISORDERS  IN  THE  MALE  AND  KEMALE.  Second 
edition.  In  cue  Svo.  volume  of  434  pages,  with  !tl  engravings  and 
13  colored  plates.     Cloth,  $3.00,  net. 

The  author  has  presented  to   the  followed,  will  be  of  unlimited  value 

profession  the  ablest  and  most  scien-  to    both    physician    and    patient. — 

tide  work  as  yet  published  on  sexual  Medical  News. 
disorders,  and  one  which,  if  carefully 

A  CLINICAL  ATLAS  OF  VENEREAL  AND  SKIN  DISEASES. 

Including  Diagnosis,  Prognosis  and  Treatment.  In  eight  large  folio 
parts,  measuring  14  1 18  inches,  and  comprising  213  beautiful  figures 
on  58  full-page  chromo-lithographic  plates,  85  tine  engravings  and  425 
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TAYLOR  (SEYMOUR).  INDKX  OF  MEDICINK.  A  Manual  for 
the  iiae  of  Senior  Students  and  otluTR,  In  one  lar^e  12mo.  volume  of 
802  pagen.     Cloth,  $.3.75. 

THOMAS  (T.  OAITifiARI))  A\l>  MUNDK  (PAUIi  F.).  A  TRAC- 
TICAL  TRKATISE  ON  Till-:  DISKASKS  OF  \V0M^:N.  Sixth 
edition.  In  one  oetavo  \()luni('  of  824  pJiKos,  with  H47  engraving". 
Cloth,  $.5;  lenther,  $«. 

TIIOHI»SO\  (W.  (illiMAV).     A    TFXT-HOOK    OF   PRACTICAL 

MFDICINF.     For  Students  and  Pnictitiuners.    Second  edition,  thor- 
oughly revised.     In    one   hiindsonio   octavo   volume   of    1014    pages, 
with  "f)!t    engravings.      Ch)tli,  .f^i.OO,   nrf ;   leather,   ifn.OO,    )ift ;    half 
Morocco,  $()..'■)(),  urt. 
Till- author  has  presented  the  rich    direct  and   most   satisfyinu'    nianner 
harvest    of    his    ripe   experience   as    he  has  giveri  in  andicient  detail  the 
physiciiiu    and    teaclier.      'i'here    is    exact  nnthod  of  treatment  that  hiis 
everywhere  iimpleevidence  of  iiccur-    commended  itself  to    his  judu'menl 
ate  observation,    profound    seholiir-    ami  his  ex|ierienci;. — Maiicul  A'cirs. 
ship  and  rare  trood  jiidutnent.     In  a 

THOMPSON  (SIR  HENRY).  THE  PATHOLOGY  AND  TREAT- 
MENT OF  STRICTURE  OF  THE  URETHRA  AND  URINARY 
FISTULA].  From  the  third  English  edition.  In  one  octavo  volume 
ot  H.5'.t  pages,  with  47  engraving.s  and  .'}  lithographic  plates.     Cloth, 

THOUNTOX  (K.  (,).).  FORMULARY.  See  Mnhru/  .\<,r.^  forl.il 
/''nnniihiri/,  page  .S2. 

TIRARD   (NESTOR).     MEDICAL   TREATMENT   OF   DISEASES 
AND  SVMIT(^MS.     Handsome  octavo  volume  of  (127  page.-*.     Chith, 
.$4.00,  vrl. 
This  work  will  rapidly  come  into    this   is  a  work  destined  to  become 
favor  with  students  and  practition-    popular,  and  we  take  great  pleasure 
ers.     It  deals  comprehensively  with    in    commending   it    in    the    highest 
therapeutical  medications  and  pre-    terms.— yri.ihvi//e  Joarind  nf  Mnli- 
sents  a  great  number  of  well-selected    cine  and  Siirrjrry. 
formulasof  every  day  use.  Certainly 

TREVES   (SIR  FREDERICK).     OPERATIVE  SURGERY.     New 

edition,  revised  by  the  author  sind  .Ionaiiian  HuTcitissoN,  .li;., 
F.R.C.S.  In  two  8vo.  volumes,  containing  1,574  pages,  with  474  illus- 
trations. De  luxe  edition,  half  Morocco,  $i).5(i,  nd,  per  volume. 
J  nxt  mnh/. 

A  SYSTEM  OF  SURGERY.     In   Contributions  by  Twenty-five 

English  Surgeons.  In  two  large  octavo  volumes,  contiiining  22rts 
pages,  with  MoO  engravings  and  I  plates.     Per  set,  cloth,  $1<).0(». 

SURGICAL    APPLIED    ANATOMY.      New   edition.      In    one 


12mo.  volume  of  .')77  pages,  with  80  engravings.     Cloth,  $2.00,  vft. 
See  Student's  Series  of  Manuals,  page  27. 

TUIiKY  (HENRY  E.).  AN  EPITOME  OF  PEDIATRICS.  12m(),, 
2(>6  pages,  ;{.3  engraving.?.  Cloth,  .'Sl,  net.  See  Ijca'x  Series <>j  McdicitI 
/'J/>iiotncs,  page  18. 

TUTTLE (GEORGE  M.).  A  POCKET  TEXT- HOOK  OF  DISEASES 
OF  CHILDREN.  In  one  handsome  12mo.  volume  of  ,374  pages, 
with  .5  plates.  Cloth,  $l..50,  vet ;  flexible  red  leather,  $2.00,  net.  See 
Lea'.'i  Series  nf    f'oe/cef    Te.rl-hooh-K,    page   IS. 


It  is  a  good  work    -the  author  liav 
ing  condensed  most  of  the  leading 
points  in  connection  with  diseases 


of  infancy  and  childhood  into  short 
and  readable  chapters. —  Virginin 
Medical  Semi-Monthl>j. 


30     Lka  Brothkrh  a  Co.,  Philadrlphia  and  New  York. 

VAUGHAN    fVICTOR    C.)    AND    NOVY    (FREDERICK    O.). 

rKl.LUI-AU  TOXINS,  or  the  Clieniieal  Fiictors  in  the  Cauaation  of 
Disease.  New  (4tli)  edition.  In  one  12nio.  volume  of  180  pages,  (loth, 
.$8.00,  nrl. 

The  work  has  heen  hrouuht  down  The  most  exhaustive  and  most  re" 

todate,  and  will    be    fousid  entirely  cent  presentation  of  the  Ruhject. — 

satisfactctry. — Joitrnn/  of  the  Ameri-  American  Jour,  of  the  Med.  Sciences, 
con  Meiiiraf  A.'^xocuttion. 

VEASKV  (CliAREXCE  A.)  A  MANUAL  <  >!'  OPIITIfALMOLOG Y. 

12mo.,410  pages,  194  engravings,  lOcolov  d  plates.     Cloth,  s2  (lO, /mV. 

The   best    eye    niiinual    we    havi'  interesting   volutne.     A   book   that 

seen.       A    handy    volume,    clearly,  should  be  constantly  in   the  han<ls 

eoneisely,     eonscrvaiively    written  of  the  student  ofophthalmology,  and 

and  wi'll  arranged.     The  treatment  one  well  suited  for  ihc  busy  oculist 

is   W(dl  up-to-date — .Inurnal     of  wiio,  in  the  midst  of  his  woil-',  may 

()]>)ilhiil iiKildijii,    OliiliKii/ (iii({  L(iri/ii-  not  have  I  inie  to  1  rok   tip    niore  e,\- 

(johx/i/.  ten.^ivc  volumes.     .S'/.  I'mil  Midini/ 

A   vei_,    at!  ractive,  uractical  and  ./onniol. 

VISITING     lilST.       tup:     MEDICAL    NEWS    VISITING    LIST. 

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JOITRNAL    OF    TlIK    MEDICAL    SCIENCES,    or    both.    See    p.    32. 

von  BER(;MAX\  (I:.).  vom  BRIXS  (P.)  and  von  MIKIMC  Z(.l.) 

A  SYSTEM  OF  I'KAC  ITCAL  SUH<  iEH  Y.  Translated  and  edr'ed 
inder  the  supervision  of  Wii  liam  T.  Bui.L,  M.D.  In  live  imperial 
octavo  volumes  containing  over  4000  pages,  with  about  MoO  engrav- 
ings and  11(1  full-piige  colond  |)hites.  Per  volui.ie,  cloth,  $i1, /m7  ; 
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The  wo'-k    is  an  cxliaustive  one,  the  series  forms  the  most  important 

and  in  its  iiitirity  will  form  a  com-  surgical  v.ork  of  the  diiy,  and  it  will 

plete  eneyclopedia  of  modern  suriri-  be  found  of  incalculable  value  to  the 

cal  kiKAvh'dge.    Aimmlimt  data,  the  studi'Ut  and  to  the  .-eientitie  ^uirgeon, 

resultof  (••■  'fnl,  oris/inal  research  in  as  relleeting  th(>  most  advai:ced  and 

special  tieh.s,  are  published,  with  ex-  approved  methods  of  modern  stirgi- 

aet  clinical   reports  that  are  of  im-  cal    practice. — Dtlrait     Mi  (lira I 

mense  practical  value.     As  a  whole,  Jinirunl. 

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WATSON  (THOMAS).  LECTITRES  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  P'lYSIC.  A  new  American  from  the  fifth  and 
enlarged  English  edition,  with  additions  bv  H.  IIartshorne,  M.  D. 
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covers  the  field  so  fully  as  to  render 
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Lka  Brothkkh  &  Co.,  Philaoklphia  and  Nkw  York.      31 

WHARTON  (HKNUY  RJ.  MINOR  SURGERY  AND  BANDAG- 
ING. Fifth  edition.  In  one  12mo.  volume  of  (ilO  paijes,  with 
509  engravings,  many  of  whicii  are  jdiutouraphic.     Cloth,  .$,S.OO,  }i(l. 

The  part  devoted  to  handagini,'  is  j  Well  written,  conveniently  ar- 
perhajjs  the  best  exposition  of  '!ie  i  rani^'cd  and  amply  illustrated.  It 
Biibjeet  in  the  i'lnulish  hnn,fuai^e.  It 
3aii  be  highly  commended  to  tlie 
student,  the  praetitioner  and  the 
specii''i.st. —  The  Chiaujo  Medical 
Recorder. 

WHITTiA  (W1L.IJAM).  DICTIONARY  OF  TREATMENT,  OR 
TIIEKAPEUTK^  INDEX.  Inoludini:  Medical  and  Surgical  Thera- 
peutics.    In  one  square  octavo  volume  of  !>17  pages.     Cloth,  $4. 

WHITMAN  (ROVAIi).  OKTIIOI'EDIC  SURGERY.  New  (2d) 
edition,  thoroughly  revised.  Octavo,  s4,3  pages,  with  50'/  engra\  iiigs, 
mostly  original.     Cloth,  .■?."). TiO,  nc/. 

The  standard  authority  on  ortho-  branch.     Tht;  text   is  clear  and  the 

pedic    surgery. —  \'iri/ini(i    Midinil  views  expressed  are  well  presented, 

Miiiilhlii.  making  the  work  the  liest  that  has 

It  is  a  pleasure  to  review  a  book  yet  been  otiered  in  this  important 

so  well  written  and  so  clearly  illus-  branch.— 77/r    Jinston    Mxlirnl  imil 

trated    as    this,    presenting    the   last  Siiri/icul  .hmriKil. 
and  best  word  on  this  active  special 

WICKS  (3IArn    -K.).     A    POCKET   TEXT-HOOK    OF    NIKSING. 

I'n  jKiriiKi.     Si'C    l.ra's    Siriis    ,ij    I'ocl.ct    'I'l  .i-l-liiinl.-s,   page  18. 

WIIJilAMS  (l>.\WSON).     THE  MEDIGVL  DISEASES  OF  GHIE- 

DRE.N.      Second   tidition.      S|,ecially  revised   for  Anu-riea  by  F.  S. 

C"  I'tiCHll.l,,  A.M.,  M.D.      In  one  octavo  volume  of  .').'{S!  pages,  with 

,52  illustrations,  and  2  plates.     Cloth,  $.'5. .")(»,  7icl. 

The  descriptions  of  symptoms  are    diagnosis,  prognosis,  complications, 

full,  and  the  treatment  recommended    and  treatment.     The  work    is  ufi  to 

will  meet  general  approval,     lender    date  in  every  sense. —  The  Chur/otte 

each  disease  are  given  the  symptoms,    }ffdic&l  Jonrnal. 

WIliSON  (ERASMUS).     A    SYSTEM    OF    HUMAN    ANATOMY. 

A  new  and  "jvised  .\merican  from  the  last  English  edition.  Illustrated 
with  397  engravings.  In  one  octavo  volume  of  6U)  pages.  Cloth,  $4; 
leather,  $5. 

AvooiiSr.v  (<ii;oRc;E).    applied  surgical  anatomy  re- 

(iloNAELY  presented.  Octavo.  .'> II  pages,  with  125  original 
illustrations  in  black  and  colors.  Cloth,. ~i:.").0<',  mt;  leather,.$(>  00,  ;/r/. 
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is  a  book  of  remarkable  merit,  show-    Scimrrs. 

Z.\PPrE  (F.  v.).  A  POCKET  TEXT  BOOK  OF  BACTERIOLOGY. 
Handsome  I2mo.  of  .'UJO  p'ucs,  amply  illustrated  with  I4H  engravings 
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